The Diabetes Epidemic: You May Have lt

The US is in the midst of a diabetes epidemic. Twenty million Americans currently have type 2 (adult-onset) diabetes, putting them at risk for such serious complications as blindness, kidney failure, heart disease, nerve damage and circulatory failure leading to amputation.

Another 41 million have prediabetes, which can turn into full-blown diabetes. The problem is that people with high blood sugar levels often don't feel any different—which is why one out of three Americans with diabetes don't even know they have the disease.

Main reason for this epidemic: More Americans are overweight and physically inactive—both of which make the body less responsive to insulin, the chemical that transports sugar from the bloodstream into the body's various cells. This condition, known as insulin resistance, forces the body to produce more and more insulin in an effort to keep blood sugar within normal limits. Among those with genetic vulnerability (including many people who aren't overweight), this eventually causes the insulin-producing cells of the pancreas to "burn out," leaving the body unable to produce enough insulin to control blood sugar.

The result: Soaring blood sugar levels.

The good news: Complications can be avoided by catching insulin resistance early and then taking basic steps to bring your blood sugar levels within normal limits.

GET A FASTING BLOOD SUGAR TEST

The best way to learn whether you have insulin resistance is a fasting blood sugar test—a simple blood draw, taken 10 to 12 hours after you've last eaten. It should be included in your annual physical. If you haven't had a fasting blood sugar test within the past year, call your primary care physician and schedule one—especially if you have a family history of diabetes.

A fasting blood sugar level of 126 milligrams per deciliter (mg/dl) or higher indicates diabetes, while a result between 100 and 125 mg/dl indicates prediabetes.

I always recommend a second test to confirm a high reading. If your test result is below 100, your blood sugar is within normal range, but you still may have early-stage insulin resistance—particularly if you are overweight or have close relatives with diabetes. If you and your doctor suspect this may be the case, you should follow the steps outlined below.

TEST FOR RISK FACTORS

Since insulin resistance is associated with significantly increased risk of heart disease, it's important that your doctor order a cholesterol (lipid) panel and check your blood pressure and body mass index (BMI). Body mass index is a measurement indicating how your weight/height ratio stacks up against the general population.

Triglyceride (a type of blood lipid) levels above 150 mg/dl and HDL (good) cholesterol levels below 50 (for women) or 40 (men), blood pressure of more than 130/80, and a BMI over 25 are all signs that you may be at risk for both heart disease and prediabetes/diabetes.

DEVELOP A TREATMENT PLAN

Some doctors still believe that there's nothing to worry about as long as your fasting blood sugar is less than 126. However, if one of my patients has a fasting blood sugar above 100 (or less than 100, but with other risk factors for insulin resistance or a family history of diabetes), I generally treat that patient as if he/she already has diabetes.

Reason: Damage from insulin resistance starts before blood sugar reaches "diabetic" levels.

This is why I urge everybody to ask their doctors for copies of their blood test results, rather than take a doctor's word that everything is OK. If your blood sugar is above 100, you need to discuss setting up a treatment plan with your doctor, or find another doctor if yours isn't responsive. This plan should include five elements...

Lose weight and exercise.
Reduce cardiac risk associated with diabetes. This includes taking a baby aspirin daily to reduce risk of heart attack and stroke, and, if your test results warrant, a statin drug to lower high cholesterol (Lipitor, Crestor), fibric acid derivatives (Lopid, Tricor) to lower triglycerides and ACE inhibitors (Lotensin, Vasotec, Zestril, Altace) or angiotensin receptor blockers (Avapro, Cozaar, Hyzaar, Diovan) to treat high blood pressure.
Test blood sugar regularly. If your fasting blood sugar test is above 100, I recommend getting another fasting blood sugar test every three months. If your blood sugar test is above 125, you’ll need to test more often. My diabetic patients do home blood tests every day, including first thing in the morning and two hours after each meal, and also get an A1C blood test every three months. This test shows what your average blood sugar level was for the previous several months. The goal is to keep your A1C below 7, and preferably between 4 and 6.
Consider diabetes medication. If your blood sugar levels continue to be high despite weight loss and exercise, you and your doctor might consider glitazone medication—either pioglitazone (Actos) or rosiglitazone (Avandia*)—to increase your body's sensitivity to insulin.

Your doctor may also prescribe metformin (which reduces the liver's glucose production and can be used with glitazones) and/or alpha-glucosidase inhibitors, such as acarbose (Precose) or miglitol (Glyset), which decrease the amount of carbohydrates absorbed by the intestines. (Unfortunately, they also tend to produce large amounts of intestinal gas.) Also, the new injected drug exenatide (Byetta) can help lower blood sugar level and weight at the same time.

If all else fails, your doctor can prescribe daily insulin doses to supplement your body's natural insulin production.

Test for complications of insulin resistance. Since cell damage from diabetes begins ready, I also recommend regular tests for complications, even if your blood sugar is only slightly elevated.

*Recent evidence suggests that Avandia may increase the risk of myocardial ischemia, a condition in which the heart muscle does not receive enough oxygen-rich blood, causing symptoms like angina. In 2007, the FDA required the manufacturers to add a severe warning label that Avandia may increase the risks of heart failure.

Reason: Diabetes-related complications may be treatable early on, but once damage becomes serious, treatment becomes difficult or impossible.

Tests include: An annual dilated eye exam by an ophthalmologist...a yearly urine test for microalbuminuria (an early sign of kidney damage)...yearly cholesterol and triglyceride tests...a check for normal foot sensation at every doctor's visit, and if numbness is detected, twice daily home foot exams for cuts or sores that you can't feel.

Losing weight is the single most effective way to prevent type 2 diabetes.

Reason: Putting on even as little as 10 pounds—especially around your middle—automatically increases insulin resistance. Losing just 15 pounds reduces your risk of developing diabetes by more than half.

A simple, proven way to lose weight: Eat smaller portions. Use small (10-inch) plates at home—and therefore serve smaller portions—since studies show that people tend to finish whatever is on their plates. Also, avoid fruit juices and soft drinks as well as "white" foods (white bread, baked potatoes and French fries, pasta, white rice), all of which cause sharp rises in blood sugar. Finally, make sure that every meal contains a mix of high-fiber fruits and vegetables and high-quality protein (fish or lean meat).

Another key: Do an hour of exercise at least five times a week. A good program for most people is 45 minutes of aerobic exercise—such as walking, biking or swimming—and 15 minutes of light weight lifting.

Reason: Regular exercise encourages weight loss and increases your body's sensitivity to insulin. This effect only lasts a short time, however, which is why it's important to exercise often.

For many, these steps will be enough to prevent diabetes. If your body's ability to respond to insulin is 75% of normal and you can lower your insulin resistance by .25% through diet and exercise—a typical response—then your blood-sugar regulation will be brought back in balance.