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Beat Diabetes Before It StartsThree years ago, Maureen Marinelli learned that she had a disease she didn't even know was a disease. She was diagnosed with impaired glucose tolerance, a symptomless condition in which blood sugar rises higher than normal -- enough to put you at risk of serious complications but not quite high enough to fit current definitions of type 2 diabetes. Her lifestyle was one great big risk factor. A U.S. Postal Service employee and official for the letter carriers' union in Boston, Marinelli, 47, spent her days embroiled in hardball politics and delicate contract negotiations. At home, she was a single mom raising a teenage son.
"It's an understatement to say that my life was stressful," she says. "I ate on the run; my idea of a good lunch was a quarter-pound burger with cheese, fries and large soda. I weighed 189 and had high cholesterol, high blood pressure and reflux from all the stress." Too often, late-night stress relief was a pack of cupcakes or the newest barbecue potato chips. And she barely had time for her passion, tap dancing. ("I'm an old hoofer," she laughs.)
There are two types of diabetes. In both, the body can't remove sugar (glucose) from the bloodstream and deliver it to cells to use for energy. A small percentage of people have type 1, in which the pancreas doesn't produce insulin, the hormone that escorts glucose into cells. Most -- 90 to 95 percent -- have type 2: Their cells resist insulin's efforts to store sugar, and their body may also produce less and less insulin over time. A year ago, the Centers for Disease Control and Prevention (CDC) in Atlanta made headlines with the shocking news that type 2 diabetes was a skyrocketing epidemic in America -- up 40 percent between 1990 and 1999 alone. The reason? We're more and more overweight and less and less active. An estimated 16 million Americans have diabetes, and at least one-third are undiagnosed and untreated. But lurking behind that troubling statistic is an even bigger, but barely mentioned shadow epidemic: 20 to 30 million Americans probably have impaired glucose tolerance. Like Maureen Marinelli, most don't know they have it. Those who do dismiss it as "a touch of sugar" or "borderline diabetes." Their doctors may call it impaired fasting glucose or impaired glucose tolerance (depending on what test was used to diagnose it) -- but often don't treat it aggressively. To underscore the danger that you shouldn't ignore, Prevention is calling this invisible and often-dismissed condition early diabetes. By any name, it's perilous, raising your risk of full-blown type 2 diabetes by 50 percent over 10 years and potentially doubling your risk of heart disease, tripling your risk of high blood pressure and making you five times more likely to die from a heart attack. Researchers are also just beginning to suspect that there may be a link between high blood sugar and some forms of cancer.
But these dangers are often downplayed -- if mentioned at all. "I call it the Rodney Dangerfield of human diseases. It doesn't get any respect," says John Buse, MD, PhD, CDE (Certified Diabetes Educator), associate professor of medicine at the University of North Carolina School of Medicine in Chapel Hill, and director of the university's Diabetes Care Center.
Fifty-five percent of Americans are overweight -- with a body mass index (BMI) of 25 or higher. And more than one-quarter have a BMI of 30 or more, a level considered obese. More kids are overweight too. As a result, diabetes is on the rise and is becoming more common among younger people as well. The CDC estimates that the number of people in their 30s with type 2 diabetes has increased 70 percent. Among children, the disease has increased tenfold in the past five years. Research also suggests that belly fat -- known as visceral fat, the kind that's packed around internal organs and is often linked to high levels of the stress hormone cortisol -- may be an even more potent risk factor than weight alone. A study of 678 Hispanic and African-American people with a family history of diabetes found that regardless of age, gender or weight, visceral fat was the most powerful factor determining who had insulin resistance -- the body's lack of sensitivity to insulin that causes early diabetes. "Overweight, a high-fat diet and visceral fat all intertwine to produce insulin resistance," says Dr. Buse. "We don't completely understand the process yet, but one theory is that people who are insulin resistant are storing excess dietary fat in all kinds of inappropriate places, such as in muscle cells and in the liver, which makes it harder for their body to use sugar as fuel," he adds. Scientists suspect that during early diabetes, high insulin levels may raise heart disease risk into the danger zone by thickening artery walls and raising blood pressure. And insulin resistance is linked to the development of a very lethal kind of bad cholesterol --small, dense LDLs -- that sets the stage for heart disease.
Quick Tip: To estimate your BMI, multiply your weight (in pounds) by 703. Multiply your height (in inches) by itself. Divide your first answer by your second answer.
Another check, called an oral glucose tolerance test, involves drinking a sugared beverage and getting a blood sugar check after two hours. If your reading is between 140 and 199 mg/dl, you have impaired glucose tolerance; 200 or higher indicates diabetes. Which test is better? New evidence suggests that the oral glucose tolerance test may catch early diabetes sooner -- and may also be a more accurate test for people over age 65. Who should be tested? Probably everyone. But if you fit the high-risk profile for diabetes (see "You're at Risk for Diabetes If You ..."), you should get tested as soon as possible.
"Knowing your blood sugar level is as important as knowing your cholesterol levels," says Robert Sherwin, MD, past president of the American Diabetes Association and director of the Diabetes Endocrinology Research Center at Yale University. "Someday, that will be common." Your doctor can perform both tests.
That's what happened in the Finnish Diabetes Prevention Study, when 523 extremely overweight people with impaired glucose tolerance tried an easy-does-it, five-point plan: Get half an hour of exercise daily; lose 5 percent of your total weight; reduce your fat intake to 30 percent of total calories; cut your saturated fat intake to less than 10 percent of total calories; and eat more fiber (more fruits, veggies and whole grains). Those who took four of the five steps didn't develop diabetes at all. Those who lost the weight and reached two other goals reduced their risk by more than 70 percent. And those who said they exercised consistently and succeeded at reaching at least two other goals cut their risk by 80 percent. "Of course we celebrated when we got the results," says lead investigator Jaakko Tuomilehto, MD, PhD, academy professor in the diabetes and genetic epidemiology unit of Finland's National Public Health Institute in Helsinki. "We think the biggest long-range health benefits will probably be the reduction in the risk of cardiovascular and renal [kidney] complications and reduction in the risk of all other major diabetes complications." Americans should expect the same results, say U.S. researchers, who recently released the findings of the landmark $174 million Diabetes Prevention Program (DPP), a study that was ended a year early because the results were so dramatic. Among its 3,224 participants (all of whom had impaired glucose tolerance), those who lost five to seven percent of their body weight and exercised for half an hour a day reduced their risk of developing full-blown type 2 diabetes by a whopping 58 percent. In contrast, those who took a diabetes drug improved their odds by only 31 percent.
"Every year that a person can live free of diabetes means an added year of life free of suffering, disability and the medical costs incurred by this disease," says Edward Horton, MD, professor of medicine at Harvard Medical School and director of clinical research at the Joslin Diabetes Center in Boston, where he is lead investigator for Joslin's part in the DPP.
"I feel good about what I'm doing," she says. "I have more energy. I'm protecting my health. I'm no saint, but now when I go to the drive-thru, I get a small cheeseburger and a diet soda."
You're at Risk for Diabetes If You
The Invisible Killer
How You Get It
What Happens to You Early diabetes raises your risk for heart disease, high blood pressure and stroke. It is linked to the thickening of artery walls and to a lethal kind of cholesterol called small, dense LDLs, which cause dangerous clogs and clots.
Full-blown type 2 diabetes also raises the odds of nerve damage throughout the body, which can lead to pain, numbness and even amputation. Early diabetes increases the chances you'll get type 2 diabetes and, eventually, damaged nerves.
Get tested now. Take a look at the risk factors above, and if you are at risk, get tested by your doctor. Get retested in six months to a year to find out if your risk has gone up or down. Nudge the scale. In a Finnish study, even extremely overweight people lowered their risk of diabetes by 70 percent when they lost just 5 percent of their total weight -- even if they didn't exercise. If you weigh 175 pounds, that's a little less than nine pounds. Cut the fat. Targets for healthy fat intake range from less than 30 percent of daily calories (less than 10 percent saturated fat) to a daily 42g fat. Prevention recommends keeping total fat intake to 25 percent of your daily calories. Rev up the fruits, veggies and whole grains.Prevention recommends nine servings of fruits and vegetables a day. Try to make at least half of your grain choices (including breads, rice and pasta) whole grain to raise your fiber intake still higher. Move a little more. People in the Finnish study who exercised the most -- up to four hours a week -- dropped their risk of diabetes by 80 percent, even if they didn't lose any weight. America's Diabetes Prevention Program (DPP) aimed for just 30 minutes of exercise, five times a week, and got big results. Moderate exercise -- walking, biking, playing tennis -- is enough to improve your odds. Befriend your diary. In both studies, keeping a food diary kept participants on track toward eating better. List what you eat, portion sizes and fat content. Enlist a coach. The secret to the success of study volunteers in both research projects was regular interaction with a registered dietitian/lifestyle counselor. "She became like my shrink, helping me get through stressful times without overeating and figuring out how to help me get past obstacles to healthier habits," says DPP participant Maureen Marinelli. Your insurance plan may not cover nutrition counseling if you're diagnosed with early diabetes. But it may if you have another health problem, such as high cholesterol, high triglycerides, high blood pressure or obesity. It's worth asking. Otherwise, try a program such as Weight Watchers. Health News Editor Sari Harrar is the staff specialist on diabetes. Paula Rasich is a researcher at the magazine.
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