With Diabetes, It’s the Complications That Kill You

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With Diabetes, It’s the Complications That Kill You

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None of us would willingly put ourselves at risk for heart disease, stroke, kidney failure, blindness, amputation or nerve damage. But if you’re one of the more than 30 million Americans who have Type 2 diabetes, you’ve already increased your risk for a cascade of serious health problems.

“If you’re diabetic,” says Rick Gillis, MD, Assistant Professor of Medicine and Director of the Office of Clinical Informatics at the Medical College of Wisconsin, “you’re six or seven times more likely to have a heart attack, and to die of it, than someone who doesn’t have the disease.” In fact, having Type 2 diabetes is as strong a risk factor for heart attack as having Coronary Artery Disease.

Diabetes mellitus (commonly called just diabetes) actually comprises a cluster of chronic illnesses in which blood glucose – the sugar used for normal body functions – isn’t utilized properly. Insulin is the fuel-regulating hormone that helps the body store and make effective use of glucose. In diabetic people, defects in insulin production or function keep the system from working properly; glucose isn’t used to provide the energy normally used for movement, cell growth and repair. In the most common form of diabetes, Type 2, muscle and fat cells are resistant to the action of insulin. Patients with type 2 diabetes may be treated with insulin to lower blood sugar.

Between 90% and 95% of the 16.7 million Americans already diagnosed with diabetes have Type 2, according to the Centers for Disease Control and Prevention (CDC). Researchers with the US Department of Health and Human Services (HHS) estimate that twice that many Americans actually have the disease – but about half don’t know it. Regardless of the exact numbers, diabetes is setting millions of Americans up for some very serious health consequences unless their disease is carefully managed.

Gradual Onset, Few Symptoms
Type 1 diabetes, formerly called juvenile-onset or insulin-dependent diabetes, is an autoimmune disease. This means that the body produces antibodies that attack and damage its own cells. It usually appears suddenly, with symptoms like excessive thirst and urination.

With Type 2 diabetes, the body might make some insulin but cannot use it effectively, leading to an unhealthy buildup of glucose (sugar) in the bloodstream. Unlike Type 1 diabetes, Type 2 develops slowly, often without symptoms. Type 2 diabetes typically develops after age 40, and it is most common in adults over 55. It was formerly called adult-onset or non-insulin-dependent diabetes, but the wording was changed in recent years to better describe the disease. Type 2 diabetes is showing up more frequently among American children and young adults.

Diagnosis and treatment of patients for diabetes is one of Dr. Gillis’ primary areas of focus in his practice; in addition, he regularly delivers presentations about diabetes to patients and to health professionals.

Blood Test Should Be Routine
Because the number of people with Type 2 diabetes is increasing so rapidly, Dr. Gillis recommends early, routine screening for the disease.

“After about age 45, everyone should routinely be screened for Type 2 diabetes,” he says, especially those whose body mass index (a weight-to-height ratio) is 25 or above, men whose waists measure 40 inches or more, and women with whose waists measure 35 inches or more. His patients take a fasting plasma glucose (FPG) blood test as part of their routine health screening tests. He also recommends this test in patients younger than 45 if they are significantly overweight or have at least one of the following risk factors:

Family history of diabetes
Low HDL cholesterol and high triglycerides (as measured in a blood test for cholesterol)
High blood pressure
History of gestational diabetes or having given birth to a baby weighing more than 9 pounds
Belong to a minority group (African-Americans, American Indians, Hispanic Americans/Latinos, and Asian American/ Pacific Islanders.
“The FPG test is a less expensive, easier to use and more reproducible test than the older oral glucose tolerance test,” Dr. Gillis says. “If the results are normal (110 milligrams per deciliter or lower), it should be repeated every three years, unless there are other risk factors. If test results are between 110 and 125, the patient may have impaired fasting glucose. Impaired fasting glucose is a pre-diabetic state, a gray area between normal metabolic function and diabetes. An FPG of 126 or greater indicates a diagnosis of diabetes, but to confirm the diagnosis, the test should be repeated on a different day.”

Obesity a Major Factor
Diabetes can be influenced by genetics, and researchers at the Medical College are engaged in a number of studies focusing on the ways genes influence diabetes and heart disease. But environment also plays a key role, especially in Type 2 diabetes, which is strongly influenced by obesity and lack of physical activity.

About 80% of Americans with Type 2 diabetes are overweight, and the number of obese Americans is increasing dramatically. In January, the federal Centers for Disease Control and Prevention (CDC) released a study in the Journal of the American Medical Association that found that the rate of diagnosed diabetes in just one year had jumped from 7.3% of the population to 7.9%. The report linked the rise to a parallel increase in the rate of obesity among Americans.

Using a body mass index of 30 or greater, the CDC study determined that 44 million Americans are obese. For example, that would translate to a 5-foot, 4-inch person who is 30 pounds or more overweight.

In April, HHS and the American Diabetic Association introduced the term “pre-diabetic” to describe individuals whose blood-sugar tests fall in the impaired category. They noted that people can delay or prevent the onset of Type 2 diabetes with “modest lifestyle improvements.” Even after Type 2 diabetes is diagnosed, patients can greatly reduce their risk of serious complications through proper care and sound diabetes management.

“Diet and exercise are the cornerstones of the treatment of Type 2 diabetes,” Dr. Gillis says. “Overweight patients who lose even 10% of their body weight – usually that means 10 to 20 pounds – can see significant improvement.” Diabetic patients also need to consult a registered dietitian and begin to follow an individualized meal plan that promotes health, he says. In his presentations to patients and their families, he recommends keeping saturated and polyunsaturated fats each to less than 10% of the diet; limiting protein to 10 to 20% of the diet; and emphasizing monounsaturated fats (like olive oil) and complex carbohydrates (fruits, vegetables and whole-grain breads, pastas and cereals) instead. And it means adjusting from a sedentary lifestyle to one with more physical activity, starting with walking regularly for exercise.

Good Management Can Keep Complications at Bay
“Treatment for diabetes involves much more than controlling blood sugar levels,” Dr Gillis notes. “People don’t get sick and die from diabetes per se, but from its complications. Uncontrolled blood sugar levels will first damage the smaller blood vessels, leading to impaired vision and reduced kidney and nerve function. Eventually the larger blood vessels can be blocked, resulting in strokes and heart attacks. With appropriate care, these results can be prevented or lessened, so the ‘complications’ must be treated aggressively.”

Recent studies have borne out the value of this approach. The January, 2003 issue of The New England Journal of Medicine reports the results of a study (Multifactorial Intervention and Cardiovascular Disease in Patients with Type 2 Diabetes) comparing the health outcomes of 80 diabetic patients receiving conventional treatment with the outcomes of 80 diabetic patients receiving intensive treatment – including behavior modification and medications targeting

high blood pressure
high blood sugar
cholesterol
microalbuminuria (protein in the urine, an early indicator of kidney damage)
The patients also used aspirin to help prevent cardiovascular disease.

The results, after a mean of 7.8 years, were significant: the intensive-treatment group fared far better than the group receiving conventional therapy. In fact, the authors note, “A target-driven, long-term, intensified intervention aimed at multiple risk factors in patients with type 2 diabetes and microalbuminuria reduces the risk of cardiovascular and microvascular events by about 50 percent.”

Patients are strongly encouraged to quit smoking, exercise regularly, and keep their cholesterol and blood pressure in healthy ranges. To that end Dr. Gillis encourages regular screenings for high blood pressure and cholesterol problems, and may prescribe medications that help control these conditions. These include ACE inhibitors (widely used in regulating hypertension), statins (used to regulate cholesterol) and low-dose aspirin.

In addition to insulin, a number of oral medications are available for patients who need drug support to regulate blood-sugar levels. These include sulfonylureas, which increase insulin release from the pancreas; metformin (Glucophage) and the thiazolidinediones, which increase tissue responses to insulin; and alpha glucosidase inhibitors, which delay the absorption of sugars from the intestine.

Dr. Gillis recommends that diabetic patients with stable, normal readings see their physicians every three to six months.

Barbara Abel
HealthLink Contributing Writer

FYI: Obese Wisconsin Residents Now Have Plenty of Company
Wisconsin once held the dubious distinction of being one of the fattest states in the country, but a recent study by the CDC shows that the rest of the country has more than caught up with us in obesity rates.

In 1985, Wisconsin was one of just eight states in which the CDC classified 10% to 14% of adults as obese. But by 1991, we were one of 35 states with obese adults in that bracket. The next year Wisconsin joined five other states with 15 to 19% of adults classified as obese; by 1999, 25 states had an obese adult population in that bracket. By 2001 (the last year measured), Wisconsin entered the 20-25% obese group, along with 34 other states. Only Mississippi has reached the next tier, being the first state to break through the 25%-plus ranks.

Article Created: 2003-01-14 Article Updated: 2003-01-14


Article Created: 2003-01-14
Article Updated: 2003-01-14


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