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Often preventable … but the numbers are increasing

Karen Miller
Rhonda M. Bentley-Lewis, M.D., M.B.A. Endocrinologist Massachusetts General Hospital

The apple or bowl of cereal or even that sugar-sweetened beverage that we consume is chock full of carbohydrates that our digestive system breaks down into glucose. It is glucose that fuels the body. There’s one hitch, though. It can’t enter the cells of muscles and other organs on its own. It needs insulin to “unlock” the cells to let it in.

In type 2 diabetes — the most common form of the disease — the body does not make enough insulin or the cells are unresponsive to it. As a result, glucose builds up in the blood, which is not a good thing. High levels of blood glucose wreak havoc on the body and can cause damage to several organs, including the heart, eyes and kidneys. They can even lead to erectile dysfunction.

The incidence of diabetes continues to rise. In 2012, more than 29 million people in this country were diagnosed with diabetes, according to the Centers for Disease Control and Prevention. What’s worse is that 8 million people do not even know they have it. It may sound odd that a person is unaware of such a serious illness, but in the initial stages, diabetes is often silent and can be detected only through testing. Even when silent, however, diabetes can be damaging.

A recent study by the CDC predicted that the disease is not going away anytime soon. Forty percent of Americans will develop type 2 diabetes at some point during their adult lives, according to new U.S. government estimates. Black women and Hispanic men and women will be hit the hardest, according to the study.

A disparity already exists. The incidence of diabetes is greater in Native Americans (15.9 percent), blacks (13.2 percent), Hispanics (12.8 percent) and Asian Americans (9 percent) than in whites (7.6 percent). Age is also a factor. Almost 26 percent of Americans 65 and older have diabetes, but young people are not exempt. The incidence of type 2 diabetes is on the rise in young people, largely attributed to the obesity epidemic.

Diabetes does not develop overnight. In prediabetes blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. Prediabetes is becoming more common in the U.S. At least 86 million U.S. adults ages 20 or older had prediabetes in 2012, according to the Department of Health and Human Services. Without a change in lifestyle, however, these cases can develop into full-blown diabetes.

Diabetes cannot be taken lightly. It accounts for $245 billion in total health care costs, trailing only heart disease and stroke. It is the seventh leading cause of death in the country, but that is probably an underestimate because diabetes is often a contributor to deaths from other chronic diseases. For instance, in Massachusetts Provisional Deaths 2011, a report from the Massachusetts Department of Health, when it is considered the underlying cause of death, diabetes ranks ninth in the state. However, when adding contributing deaths, such as stroke or heart attack, it ranked third.

There are several symptoms of diabetes, including increased thirst, frequency of urination, blurred vision, fatigue and tingling in the hands and feet. And even weight loss.

“This is one situation where losing weight is not a good thing,” said Dr. Rhonda Bentley-Lewis, an endocrinologist at Massachusetts General Hospital. An endocrinologist specializes in the treatment of diabetes and other gland disorders. “The increased urination is associated with an increase in loss of glucose in the urine, which is associated with a loss of calories,” she explained. Some patients expect frustration when Bentley-Lewis starts them on insulin because, although their glucose is better controlled, they begin to gain weight.

The key to controlling diabetes is early detection, but screening recommendations vary by organization. The American Diabetes Association recommends screening for diabetes in people who are overweight and have any of several risk factors, including physical inactivity, first-degree relative with diabetes, minority race or high blood pressure.

Screening may be as simple as having a fasting blood glucose or A1C test. These are inexpensive, low-risk tests that are potentially high reward if you can identify someone with diabetes early, she explained.

Some factors have more impact than others. “The obesity epidemic and the diabetes epidemic go hand in hand,” said Bentley-Lewis. Although body weight matters, the distribution of fat is also important. Central obesity — fat that accumulates around the waist — is metabolically active and a greater risk factor for diabetes and heart disease than fat elsewhere, such as the hips or thighs. Unfortunately, waist sizes are burgeoning.

While the overall obesity rate is stabilizing, abdominal obesity is on the rise. A study published in the Journal of the American Medical Association noted that between 1999 and 2012 the average women’s and men’s waist size increased by 1.5 inches and .8 inches, respectively.

The risk for diabetes and heart disease increases with a waist measurement that is greater than 35 inches for women and greater than 40 inches for men.

Age is another strong risk factor. “We want to age, but we want to age well,” Bentley-Lewis explained. “Unfortunately, as we age, we may become less physically active, gain weight and lose muscle mass, all of which increase our risk for developing diabetes.” In addition, the cells in the pancreas age with us and its ability to provide the insulin needed will become impaired over time. However, we can support pancreatic function by maintaining healthy activity and eating habits, she explained.

The point that Bentley-Lewis continues to hammer home is that diabetes is largely preventable, or controllable once diagnosed. The key is a healthy lifestyle, which includes a healthy eating plan, not smoking, regular physical activity and weight loss if overweight or obese. “Losing as little as 5 to 7 percent of body weight can improve the body’s ability to use insulin effectively,” she said. Taking medications, including pills or insulin, as prescribed, is also key for those with the disease.

Although bariatric surgery (weight loss surgery) has been touted as a “cure” for diabetes, “I do not recommend it to control diabetes,” she explained. “It does not address the underlying problem. It may be a quick fix, but there is no substitute for lifestyle changes involving physical activity and healthy eating.”

There is some good news to share regarding diabetes. A recent CDC study showed that rates of five diabetes-related complications — amputation, end-stage kidney failure, heart attack, stroke and deaths due to high blood sugar — declined substantially in the last 20 years.

Bentley-Lewis is not surprised. Early diagnosis and treatment of diabetes will help prevent the damage high blood glucose levels inflict on nerves and blood vessels over time.

There’s more good news. If a person adopts a healthy lifestyle early in the course of the disease and incorporates healthy eating and exercise as a regular routine, it is possible to maintain blood glucose without the benefit of medicines and insulin.

Bentley-Lewis said she recognizes the difficulty in living with the disease.

“I know how challenging managing diabetes can be and how it can change every aspect of your life,” she said.