Two reports released this week shed light on the current state of type 2 diabetes in this country, and their conclusions are promising and sobering. First, the good news: An article in The New England Journal of Medicine shows that rates of diabetes-related problems like heart attack, stroke, and lower-limb amputation are down by more than 50% over the last two decades. Now the bad news: during the same time period, the number of people with diabetes has soared, according to a report in the Annals of Internal Medicine. Today, about 21 million American adults are living with diabetes, and that number is on the upswing. Nearly 70% of Americans are overweight or obese. Unless something is done to reverse this trend, millions more Americans could edge closer to diabetes. Dr. Osama Hamdy, medical director of the Obesity Clinical Program at Harvard-affiliated Joslin Diabetes Center and author of The Diabetes Breakthrough, a newly published book from Harvard Health Publications, offers some strategies for preventing diabetes.
There are many reasons to keep your blood sugar under control: protecting your arteries and nerves are two of them. Here’s another biggie: preventing dementia, the loss of memory and thinking skills that afflicts millions of older Americans. A study published today in the New England Journal of Medicine shows that even in people without diabetes, above normal blood sugar is associated with an increased risk of developing dementia. The study does not prove that high blood sugar causes dementia, only that there is an association between the two. For that reason, don’t start trying to lower your blood sugar simply to preserve your thinking skills, cautions Dr. Nathan. There’s no evidence that strategy will work, although he says it should be studied. But it is still worth keeping an eye on your blood sugar. Excess blood sugar can lead to diabetes and a variety of other health problems, including heart, eye, kidney, and nerve disease.
An old, aspirin-like drug called salsalate could help control blood sugar in people with type 2 diabetes. In the TINSAL-T2D trial, 286 volunteers took pills containing either salsalate or a placebo for nearly a year. Over the course of the trial, those in the salsalate group had lower blood sugar levels, and some were even able to reduce dosages of other diabetes medications they were taking. Experts aren’t exactly sure how salsalate helps control blood sugar, but its effectiveness supports the idea that inflammation plays a role in type 2 diabetes. Although the results are promising, what we really need to know about salsalate (or any new or repurposed drug) is how its long-term benefits and risks stack up against each other. The trial was too small and too short to determine those risks. According to the researchers, such “outcomes require continued evaluation before salsalate can be recommended for widespread use” by people with type 2 diabetes.
Long-awaited results from a nearly 10-year trial exploring the effect of changes in diet and exercise among people with diabetes weren’t what most people expected. The Look AHEAD trial found that intensive efforts to lose weight by eating less and exercising more didn’t provide any more protection against heart disease—a common co-traveler with diabetes—than standard diabetes support and education. The spin from some media reports is that weight loss doesn’t reduce heart disease risk among people with type 2 diabetes, but I think that’s the wrong interpretation. The results of the Look AHEAD trial don’t contradict the value of lifestyle changes. People in the intensive change group improved their blood sugar with fewer drugs, saving an estimated $600 per year, they were also less likely to have developed chronic kidney disease and less self-reported vision problems. The Look AHEAD results reinforce for me that diabetes care needs to be tailored to the individual.
City dwellers often think of rural America as a throwback to past “good old days.” But when it comes to obesity and diabetes, people living outside urban areas offer a frightening glimpse of the future. While more than 8% of Americans now have diabetes, in some rural counties 20% of the residents have diabetes. Those counties also tend to have high rates of obesity. Barriers to healthy living contribute to both obesity and diabetes. So does lack of primary care physicians. One answer may be greater reliance on community health workers—lay people trained to provide diabetes education and outreach. In Birmingham, Alabama, the Cities for Life program has doctors refer people with diabetes to “patient navigators” who help them find local resources such as nearby exercise classes or mobile farmers’ markets.
A lot is known about diabetes. But a discovery that could change how this disease is treated shows just how much more there is to learn. A team of Harvard Medical School researchers has discovered a hormone called betatrophin made by liver and fat cells that signals the body to make more insulin-producing beta cells. A report of their work appears in this month’s issue of the prestigious scientific journal Cell. In mice with diabetes, experimentally turning on the production of betatrophin inside liver and fat cells caused an increase in beta cells and a dramatic improvement in blood sugar. It will, of course, take much more research in mice—and then in humans—to determine if this newly discovered hormone can serve as a treatment for diabetes. So it’s too soon to get excited that the discovery of betatrophin will translate directly into a new treatment for diabetes. But it is another example of the human body’s power to naturally repair itself.
Type 2 diabetes doesn’t usually appear all of a sudden. Many people have a long, slow, invisible lead-in to it called prediabetes. During this period, blood sugar levels are higher than normal. However, they’re not high enough to cause symptoms or to be classified as diabetes. It’s still possible at this stage to prevent the slide into full-blown diabetes. Think of prediabetes as a wake-up call. Unfortunately, few people ever hear the alarm. A new report from the Centers for Disease Control and Prevention shows that among Americans age 20 and older, only 10% of those with prediabetes know they have it. Given that as many as 73 million Americans have prediabetes, that’s a lot of missed opportunities to prevent the ravages of diabetes. One reason many people don’t know that they may be headed toward diabetes is they’ve never had their blood sugar tested. This simple test isn’t part of routine preventive care, but perhaps it should be.
If you like numbers and statistics, especially those about health, two reports released this week should keep you occupied for days: the massive Global Burden of Disease study was published in The Lancet, and the American Heart Association released its annual “Heart and stroke statistics” report. The Global Burden of Disease project found that average life expectancy continues to rise in most countries. It also found that infection and other communicable causes of disease no longer dominate deaths and disability. Today, so-called non-communicable causes like traffic accidents, violence and war, heart disease, cancer, and other chronic conditions account for two-thirds of world deaths and the majority of years lost to disability and death. According to the American Heart Association’s annual report, the percentage of deaths due to heart attack, stroke, and other cardiovascular diseases has fallen by nearly one-third since 1999, but don’t expect that to continue. Increases in high blood pressure, high cholesterol, diabetes, overweight, and inactivity threaten to reverse these gains.
Many medical studies confirm what we know or suspect. Every once in a while, though, one surprises us, turning “conventional wisdom” on its head. That just happened with the sudden shutdown of a long-running diabetes trial called Look AHEAD (Action for Health in Diabetes). Begun in 2001 and scheduled to last another two years, Look AHEAD was designed to see if an intensive diet and weight loss program could reduce the number of heart attacks, strokes, and other cardiovascular problems in people with type 2 diabetes. An early peek at the data showed that the program had little apparent effect, and the investigators concluded it would be futile to continue. This does not mean that we should ignore diet and exercise in treating of type 2 diabetes. Instead, the details of the study results, which haven’t yet been published, are likely to reveal other explanations.
As part of its 200th anniversary celebration, today’s New England Journal of Medicine carries an article called “The Past 200 Years in Diabetes.” It describes some of the advances made in understanding and treating this disease, like the discovery of insulin and the development of personal blood-sugar monitors. But it doesn’t tell much about how living with diabetes has changed. Just 50 years ago, checking blood sugar and administering insulin were big ordeals, and people with diabetes weren’t expected to live more than a few years after their diagnoses. today, it’s a cinch to check blood sugar with a quick finger prick, and pen-like devices almost painlessly deliver insulin, and people with diabetes who take care of themselves have almost normal life expectancies. Advances in protecting and treating the heart, eyes, kidneys, and limbs have helped reduce complications from diabetes.