Undiagnosed Diabetes

Diabetes results from the body's failure to produce enough insulin or to use it properly. The disease, which afflicts an estimated 17 million Americans of all ages can be fatal, or result in blindness or amputations. A panel of experts in the field also advises doctors to take steps to identify people who have pre-diabetes so that preventive steps can be taken to delay the onset of diabetes. Diabetes is the 6th leading cause of death in the U.S., and the major cause of blindness in this country.

According to researchers from Harvard University's School of Public Health nuts and peanut butter may help ward off adult-onset diabetes in women. The researchers analyzed data on 83,818 nurses ages 34 to 59 who had been followed for up to 16 years. The results of the study appeared in the November 27, 2002 issue of The Journal of the American Medical Association. Past research has indicated that nuts that contain unsaturated fats as well as other nutrients that can help keep cholesterol at healthy levels. Some brands of peanut butter may contain high amounts of sugar or fatty preservatives, so consumers are advised to read the labels carefully.

A coalition of diabetes associations, with the financing from Aventis, the French pharmaceutical company, has embarked on an educational campaign in connection with a relatively cheap blood test that measures the percentage of glucose, or sugar, attached to red blood cells in the bloodstream. The test is called the A1C test and it costs about $75 on top of a doctor's visit.

In the A1C test, a person without diabetes usually has a rating of less than 6%. Anything over 7% indicates an excess of sugar. The excess sugar in your body's system is what eventually will damage various organs that are essential to the proper functioning of your body. Of the estimated 17 million people who have diabetes, it is estimated that over 6 million of them are unaware that they have the problem. Although Aventis is one of the largest manufacturers of diabetes testing equipment so it does have a vested interest in the campaign which is being marketed by the Burston-Marstellar advertising firm.

There are 3 main types of diabetes. Type 1 occurs in children and young adults. Type 2 diabetes is also known as adult onset diabetes, and it accounts for 90% to 95% of the diabetes in the U.S. Type 2 diabetes can be controlled through diet that avoids excessive amounts of sugar and carbohydrates, (that the body turns into sugar) and through exercise. Type 3 diabetes is also called gestational diabetes and affects about 2% to 5% of pregnant women, and usually goes away after they give birth.

The number of people with diabetes has tripled in the past 30 years, and diabetes now ranks as one of the most expensive health problem in the U.S. It is estimated that the disease cost about $98 billion in 1997, the last year for which there is an estimate given by the American Diabetes Association.

A panel of experts recommended that doctors screen patients who are overweight and who are 45 or older for pre-diabetes. While white people have a lower risk factor (7.8%) than do blacks (13 %), Hispanics (10.2%) or American Indians or Alaska natives (15.1%) the testing is important for everyone. A family history of diabetes is also important in determining both diabetes and pre-diabetes inclinations.

We recently found this chart in Patient Care 2003; 37(9):27 which summarized the levels of blood pressure recommended for patients with diabetes by various national organizations.

Organization Year BP (mm Hg)
Joint Ntl Committee on 2003 <130/80
Prevention...High BP

Amer College of Physicians 2003 <135/80

Amer Diabetic Association 2001 <130/80

N'tl Kidney Foundation 2000 <130/80

Canadian Hypertension 1999 <130/80

There are two blood tests that identify diabetes that can also be used to identify pre-diabetes. One of the tests measures for impaired glucose tolerance wherein a blood-sugar measure between 140 and 199 milligrams a deciliter indicates pre-diabetes. The other test detects impaired fasting glucose. If the blood-sugar level after an overnight fast is between 110 and 125 milligrams per deciliter, that also indicates a pre-diabetes condition.

Dr. David Edelman and colleagues (J Gen. Med. January 2002) has done research on the prevalence and severity of undiagnosed diabetes in a clinical outpatient setting, as opposed to a hospital in-patient setting or a general population setting. The study involved 1253 outpatients age 45 to 65, who where healthy as far as a diagnosis of diabetes and were being seen in the outpatient clinic.

This meant that there was no record of a diabetic diagnosis in their medical history. These individuals were then followed for 2.5 years at the Durham Veterans Medical Center. All were initially screened for diabetes using a hemoglobin A1C test. If an individual obtained a score equal to or greater than 6.0% on this test, they were then given a fasting plasma glucose test. Using scores obtained on these two tests for diabetes diagnosis (AlC score >7.0% and fasting plasma glucose greater than 7 mm/L), they found 4.5% of these patients had undiagnosed diabetes. In this group, 61% had a "treatment altering diagnosis" suggesting that they required initiation of treatment for diabetes or a change in the treatment of a comorbid illness (i.e., hypertension, hyperlipidemia).

Dr. Edelman, an assistant professor of medicine at Duke University Medical Center states: "The benefits of detecting diabetes, such as preventing heart attacks, generally accrued 10 to 15 years after the diagnosis, but there could be similar benefit to screening older patients." He feels there is a greater need to test for diabetes in older people and that people up to age 80 might benefit from diabetes screening. He indicates that treating the diabetes may result in short-term improvement in cognition, a not so insignificant benefit in the aging process.

Approximately 15.6 million people in US aged >20 yrs. (7.8% of the population) suffer from diabetes mellitus. Diabetes mellitus is 10 times more prevalent in individuals over 65 years of age than in those 20 to 40 years. The incidence of type 2 diabetes increases dramatically with increasing age, affecting >10% of the elderly population (>65 years) in the US. Older subjects with diabetes have more complications than younger counterparts, as well as higher morbidity and mortality rates compared with age-matched subjects without diabetes. The Framingham study described the development of diabetes in later life to be associated with hypertension, vascular lesions, elevated very-low-density lipoprotein (VLDL) cholesterol, use of diuretics and obesity.

The patient with diabetes is twenty-five times more likely to become blind, seventeen times more likely to develop kidney disease, twenty times more likely to develop gangrene and two times more likely to suffer a stroke or heart attack than age matched cohorts without disabilities.

A key objective in the treatment of diabetes is normalization of the blood glucose level. Dietary control and exercise are a first line therapy. Carbohydrates and glucose in particular, are an important source of energy for most living organisms. Tissues such as the brain need glucose constantly, and low concentrations of glucose can cause seizures, loss of consciousness, and death.

High blood glucose concentrations, as found in poorly controlled diabetes, can result in blindness, renal failure, cardiac and peripheral vascular disease, and neuropathy. When these first line treatments are found inadequate to control glucose level, pharmacological treatment with oral hypoglycemia agents becomes necessary. This would also indicate that blood glucose concentrations have to be maintained within a narrow limit, not too high or too low for optimal health.

Diabetes and its complications remain a huge health problem. Biotechnology companies are racing to develop new therapies that aim to go beyond just treating symptoms but attack the causes of the disease, in which the pancreas shuts down or fails to produce the correct amount of insulin hormone, causing dangerously high blood-sugar levels.

Amylin Pharmaceuticals Inc. is working on developing a genetically engineered version of a hormone that is normally produced in pancreas cells as insulin. At the same time it is trying to control adverse side effects such as weight gain, increased cholesterol and sudden drops in blood sugar, a not so uncommon side effect of insulin therapy. Another company, Ligand Pharmaceuticals of San Diego is researching a drug that intervenes directly between insulin and the proteins it interacts with inside cells to regulate blood glucose. It belongs to a group of drugs known as retinoids that work within individual cells. Its goal is to block destructive oxygen-carrying molecules that attack the pancreas, cause resistance to insulin and they contribute to some serious side effects.

We would urge all individuals to consult with their primary care physicians, check for diabetes and institute therapies necessary to bring glucose levels within normal limits. Its future health benefit is worth the present treatment.



By Harold Rubin, MS, ABD, CRC, Guest Lecturer
posted October 5, 2003

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