New Fronts In the War On Diabetes In Adults

[Guest guest]

Thought the following article on Type 2 and how diet and exercise is being

tested to see if possibly they can " prevent " Type 2 diabetes.

God's Speed. ***Robin***

To: newsdeskegroups

The New York Times

September 7, 1999, Tuesday, Late Edition - Final

New Fronts In the War On Diabetes In Adults

By DENISE GRADY

Her brother, an uncle, two aunts, two first cousins and a nephew:

Louise

quickly reels off a list of relatives with diabetes. Her

parents may

have had it, too, she guesses, since both died in their 40's from

heart attacks,

a common complication of diabetes.

A cousin died from the disease in June after suffering its most

dreaded

complications, including blindness, kidney failure, heart attacks and

infections

in her feet that would have led to amputations had she lived. The

cousin was in

her 50's, like Ms. , and the two had been close.

Like many people who have seen family members suffer and die from

diabetes,

Ms. has been living with the uneasy sense that the disease

lurks in her

genes and sooner or later may catch up with her.

But about a year ago, she learned that for her, the disease might

not be

inevitable. Ms. volunteered for a six-year study in which

researchers

are prescribing a drug or diet and exercise to try to prevent diabetes

in people

like her who are at high risk for the disease. The study, the Diabetes

Prevention Program, is being conducted at 27 medical centers around

the United

States, including St. Luke's-Roosevelt Hospital in Manhattan and

Albert Einstein

College of Medicine in the Bronx. (The study is full, and no centers

are

accepting new participants.)

Ms. , who lives in Brooklyn, does not mind taking the

45-minute

subway ride to St. Luke's-Roosevelt every three weeks.

" I think it's great, " she said. Her daughter, in her 20's, wishes

she had

signed up, too.

The study is one front in an intensifying war on Type 2 diabetes, a

progressive, debilitating disease that has been gaining ground at an

alarming

rate in recent years -- partly, researchers say, because of a growing

tendency

among Americans to inactivity and weight gain.

Also called " adult onset " because it usually develops after age 30,

it is by

far the most common type of diabetes; it has been diagnosed in more

than 9

million Americans, and 5.4 million more are estimated to have it

without knowing

it. Treatment costs exceed $100 billion a year. (Type 1, or juvenile,

diabetes

occurs in younger people and affects about a million Americans. Its

causes are

different from those of Type 2.)

Just last week, in the journal Circulation, the American Heart

Association

and four other public health groups urged doctors to be more

aggressive in

treating people with Type 2 diabetes, because the disease strongly

increases

their risk of strokes and heart attacks. People with diabetes usually

have high

cholesterol and high blood pressure and tend to be obese and inactive.

All those

conditions are risk factors for cardiovascular disease, and all need

to be

treated along with the diabetes itself, the groups said.

At the same time, the National Institutes of Health announced that

two new

studies would be started this year to test more intensive treatment of

people

with those risk factors in an effort to reduce their rates of

cardiovascular

disease.

Researchers think the disease is caused by a combination of genes,

not yet

identified, but also by life style: in people who are genetically

predisposed,

inactivity and weight gain can bring on the disease, and the risk is

heightened

with age. And certain ethnic groups appear to have a strong genetic

susceptibility to Type 2 diabetes, including blacks, Hispanic

Americans,

American Indians, Asians and Pacific Islanders.

" The incidence of Type 2 diabetes has skyrocketed, " said Dr.

Foo, an

endocrinologist working on the diabetes prevention study at St.

Luke's-Roosevelt. " This was a disease that 50 or 60 years ago was in

50- or

60-year-old people. Now we're starting to see teen-agers with it. It's

very,

very concerning. We're seeing a great deluge of masses of people

becoming

overweight. We must focus on prevention. If we don't do something

about it,

we're going to have an epidemic on our hands and a national health

crisis. "

The classic sign of diabetes is an abnormally high blood level of

glucose, a

type of sugar. Glucose builds up because diabetics lack or cannot

properly use

the hormone insulin, which is made by the pancreas to help glucose

enter cells

all over the body so that it can be used as fuel.

Without the help of insulin, glucose accumulates in the

bloodstream, where it

can damage blood vessels, eventually injuring the kidneys, eyes and

nerves,

cutting off circulation to the feet and legs and raising the risk of

heart

disease and strokes. People with Type 2 diabetes produce insulin, but

tend to

have a condition called insulin resistance, in which their bodies

cannot use it.

The link between diabetes and cardiovascular disease has been known

for a

long time, but it has become more of a concern recently, because

research

suggests that heart disease is not only more common among people with

diabetes

but may also be more severe.

A study of about 18,000 patients published in The Journal of the

American

Medical Association in April found that although deaths from heart

disease had

declined in the United States in recent decades, the decline was far

less

pronounced in people with diabetes. In nondiabetic men, the decline

was 36.4

percent; in diabetic men, it was only 13.1 percent. And diabetic women

actually

had a 23 percent increase in deaths, compared with a 27 percent drop

for women

without diabetes. Reasons for the striking differences are not known.

" There are lots of data showing that our health system is failing

to take

good care of people with diabetes, " said Dr. Bruce Zimmerman,

president of the

American Diabetes Association and an endocrinologist at the Mayo

Clinic in

Rochester, Minn. Many patients need careful treatment to control

cholesterol,

triglycerides and blood pressure as well as blood sugar, but, he said,

they do

not always get it.

But severe complications can develop even in people who are treated

correctly, suggesting that in some, artery damage may occur even in

the earliest

stages of the disease. That realization has heightened the interest in

prevention.

Researchers think most cases of Type 2 diabetes begin with insulin

resistance, which is probably a genetic trait that may occur years

before

diabetes develops, perhaps during adolescence. Because the body cannot

use

insulin efficiently, the pancreas churns out more and more of it in an

effort to

keep blood sugar normal. That works for a time, but gradually

insulin-producing

cells in the pancreas wear out, and blood sugar levels begin to rise,

until

diabetes develops. Weight gain and lack of exercise make insulin

resistance

worse, and high-fat diets may also contribute.

Insulin resistance itself, even without high blood sugar, is

already

associated with abnormal blood fats, high blood pressure and heart

disease. The

condition can be detected by research laboratories, but there is no

simple test

that can be easily performed as part of a checkup. About 60 million

Americans

are estimated to be insulin-resistant; only a quarter of them go on to

become

diabetic, but all are thought to be at increased risk of

cardiovascular disease.

" We may be setting the stage for heart disease early, even before

the glucose

goes up, " Dr. Zimmerman said.

In a study published in the September issue of the journal

Diabetes,

researchers studying people in Sicily reported that they had

identified the

first gene ever linked to the form of insulin resistance that occurs

in Type 2

diabetes. The gene directs the body to produce a protein that can

interfere with

insulin's ability to open channels that let glucose enter cells.

Dr. Ira Goldfine, an author of the study and a professor of

medicine and

physiology at the University of California at San Francisco, said the

finding

might lead to development of a drug that could treat insulin

resistance by

blocking the protein and letting insulin do its job.

" We think the protein would be a very good target for a

pharmaceutical

company, " he said.

But that would be a long way off, he said, and it would not work

for all

patients, because not everyone with insulin resistance makes the

abnormal

protein, and not everyone who makes the protein is resistant. Other

genes must

also play a role.

In the meantime, researchers are trying other ways to prevent

diabetes. The

six-year study at St. Luke's-Roosevelt and other hospitals is

comparing the

effectiveness of diet and exercise with that of drug therapy.

Ms. qualified for two reasons. Somewhat overweight at 5

feet 6

inches and 157 pounds, she also had impaired glucose tolerance, a

common

precursor of diabetes: when she was given a sugary drink, her blood

glucose rose

abnormally, though not so high as it does in diabetes.

Once accepted into the study, she was assigned at random to a group

that

would try intensive changes in diet and exercise to lose weight and

improve

glucose tolerance. Although those measures are used to treat Type 2

diabetes,

they have not been tested as a means of prevention. Other participants

were

assigned to a group in which they were given either a placebo or a

diabetes

drug, metformin, which can help lower blood sugar.

Working with a nutritionist, Ms. set a goal of losing 12

pounds and

began walking, stretching and riding an exercise bicycle. She also

reduced the

amount of fat in her diet and began eating more fruits and vegetables

and small

amounts of lean meat and poultry.

" I was a meat and potatoes and bread person, " she said. " A big

steak would

make me happy, with french fries. I ate a lot of pizza and processed

meat and

red meat. Now, I no longer eat those things. I have no desire for

them. "

Within eight months, she had lost the 12 pounds. Later, she dropped

two more,

and they have stayed off. Others in the study have struggled with

weight loss,

however, losing weight and gaining it back and starting all over

again.

" I look better and I feel better, " Ms. said. Her energy

has gone up

and her blood pressure, blood sugar and dress size have all gone down.

She does

not think she will have any trouble sticking with the changes. " It's

the best

thing that happened to me, " she said. " I'm hoping I can avoid diabetes

entirely.

If that doesn't work, at least maybe it will be quite a while before I

get it. "

The study will continue until 2002. Dr. Zonszein, an

endocrinologist at

Albert Einstein College of Medicine, who is working on the program,

said: " We

are looking at the possibility of delaying the onset of diabetes. I

don't think

we're going to abort it entirely, but I think we could delay it, maybe

by 5 or

10 or 20 years. "