Diabetes is becoming more widespread in the United States each year. Almost everyone knows someone who has diabetes. An estimated 17 million people in the United States, 6.2 percent of the population, have diabetes mellitus - a serious, lifelong condition. Of those who are 20 years of age or older, 16.9 million or 8.6% have diabetes. People age 65 years or older account for 7 million cases of diabetes and represent 20.1 percent of all people in this age group. Fully one-third or about 5.9 million people have not yet been diagnosed and 11.1 million people have a confirmed diagnosis of diabetes. Each year, about 1 million people age 20 and older are diagnosed with diabetes. About 151,000 people less than 20 years of age have diabetes. This represents 0.19 percent of all people in this age group. Approximately one in every 400 to 500 children and adolescents has type 1 diabetes. Clinic-based reports and regional studies indicate that type 2 diabetes is becoming more common among American Indian, African American, and Hispanic/Latino children and adolescents.

• Men: 7.8 million. 8.3 percent of all men have diabetes.

• Women: 9.1 million. 8.9 percent of all women have diabetes.

• Non-Hispanic whites: 11.4 million. 7.8 percent of all non-Hispanic whites have diabetes.

• Non-Hispanic blacks: 2.8 million. 13 percent of all non-Hispanic blacks have diabetes. On average, non-Hispanic blacks are two times more likely to have diabetes than non-Hispanic whites of similar age.

• Hispanic/Latino Americans: 2 million. 10.2 percent of all Hispanic/Latino Americans have diabetes. On average, Hispanic/Latino Americans are 1.9 times more likely to have diabetes than non-Hispanic whites of similar age. Mexican Americans, the largest Hispanic/Latino subgroup, are two times more likely to have diabetes than non-Hispanic whites of similar age. Similarly, residents of Puerto Rico are two times more likely to have diagnosed diabetes than U.S. non-Hispanic whites. Sufficient data is not available to derive more specific current estimates for other groups.

Diabetes mellitus is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. Diabetes can be associated with serious complications and premature death, but people with diabetes can take steps to control the disease and lower the risk of complications.

Diabetes is a disorder of metabolism - the way our bodies use digested food for growth and energy. Most of the food we eat is broken down into glucose, the form of sugar in the blood. Glucose is the main source of fuel for the body; especially the brain.

After digestion, glucose passes into the bloodstream, where it is used by cells for growth and energy. For glucose to get into cells, insulin must be present. Insulin is a hormone produced by the pancreas, a large gland behind the stomach. when we eat, the pancreas is supposed to automatically produce the right amount of insulin to move glucose from blood into our cells. In people with diabetes, however, the pancreas either produces little or no insulin (type 1), or the cells do not respond appropriately to the insulin that is produced (type 2). Glucose builds up in the blood, overflows into the urine, and passes out of the body. Thus, the body loses its main source of fuel even though the blood contains large amounts of glucose. A relative lack of glucose going to the muscles results in fatigue, which causes many to seek medical care. There are three main types of diabetes, they are: Type 1 Insulin Dependant Diabetes, Type 2 Non-insulin Dependant Diabetes and Gestational (Pregnancy) Diabetes. Of the three types, type 2 is by far the most common and the most amenable to comprehensive treatment.

Type 1 diabetes was previously called insulin-dependent diabetes mellitus (lDDM) or juvenile-onset diabetes. Type 1 diabetes develops when the body's immune system destroys pancreatic beta cells, the only cells in the body that make the hormone insulin that regulates blood glucose. The pancreas then produces little or no insulin. Someone with type 1 diabetes needs to take insulin daily to live. This form of diabetes usually strikes children and young adults, who need several insulin injections a day or an insulin pump to survive. Type 1 diabetes may account for 5 to 10 percent of all diagnosed cases of diabetes. Risk factors for type 1 diabetes include autoimmune, genetic, and environmental factors. Symptoms of type 1 diabetes usually develop over a short period, although beta cell destruction can begin years earlier. Symptoms include increased thirst and urination, constant hunger, weight loss, blurred vision, and extreme fatigue. If not diagnosed and treated with insulin, a person can lapse into a life-threatening diabetic coma, also known as diabetic ketoacidosis.

The most common form of diabetes is type 2 diabetes. type 2 diabetes was previously called non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes. About 90 to 95 percent of people with diabetes have type 2. This form of diabetes usually develops in adults age 40 and older and is most common in adults over age 55. A rapid increase in the younger population is now being seen. What was once a traditional "middle-age" onset disease has now infiltrated the young adult and even children. This alarming increased rate in younger patients has sparked the attention of the medical industry to actively begin educational outreach programs to increase awareness in both patients and providers.

About 80 percent of people with type 2 diabetes are overweight. Type 2 diabetes is often part of a metabolic syndrome that includes obesity, elevated blood pressure, and high levels of blood lipids. Unfortunately, as noted above, 25% of children and adolescents are now overweight and type 2 diabetes is becoming more common in young people.

When type 2 diabetes is diagnosed, the pancreas is usually producing enough insulin but the body cannot use the insulin effectively, a condition called insulin resistance. The body senses this lack of effectiveness and frequently increases its production of insulin erroneously to regulate elevated blood glucose levels. After several years of overproduction, or hyperinsulinism, insulin production decreases. The result is the same as for type 1 diabetes; glucose builds up in the blood and the body cannot make efficient use of it as a main source of fuel. The excess glucose in the blood stream is then converted to storage energy, i.e. fat. Excess glucose metabolites triglycerides are sent fatty tissues to be saved for a rainy day - that frequently never comes for many patients.

The symptoms of type 2 diabetes develop gradually. They are not as sudden in onset as in type 1 diabetes. Some people have no symptoms, or difficult to recognize symptoms which may include fatigue or nausea, frequent urination, unusual thirst, weight loss, blurred vision, frequent infections, and slow healing of wounds or sores. Fully a third of diabetics are walking around undiagnosed by the best health care industry on the planet! In my opinion, the screening parameters set forth by the American Diabetic Association are only fueling this missed opportunity to uncover diabetes at the earliest stage. I will discuss my recommendations for improved screening later in this newsletter.

Gestational diabetes is a form of glucose intolerance that is diagnosed in some women during pregnancy. Gestational diabetes occurs more frequently among African Americans, Hispanic/Latino Americans, and American Indians. It is also more common among obese women and women with a family history of diabetes. During pregnancy, gestational diabetes requires treatment to normalize maternal blood glucose levels to avoid complications in the infant. Though it usually disappears after delivery, the mother is at increased risk of getting type 2 diabetes later in life. After pregnancy, 5 to 10 percent of women with gestational diabetes are found to have type 2 diabetes.

The term "insulin resistance" describes a condition of the reduced sensitivity of a cell to the action of insulin. Insulin must bind "effectively" to the cell receptor as one of the first steps in appropriate glucose metabolism. If insulin is less than effective at the receptor, glucose levels tend to rise signaling a "need" for more insulin. The body responds by secreting excessive insulin, at times reaching 4-5 times the expected physiologic level. This secondary hyperinsulinemia can have a deleterious effect on the pancreas as it tries in vain to keep up with this excessive demand. The pancreas begins to fail and sets the stage for type 1 diabetes. Eager physicians are quick to prescribe a first or second-generation diabetic medication, betting on the pancreas to produce even more insulin and further hastening the demise of the pancreas beta cells. This insulin resistance or insensitivity leads to glucose intolerance and dysglycemia. Insulin Resistance Syndrome (IRS) also referred to as Syndrome X or Metabolic Syndrome refers to a set of metabolic abnormalities.

IRS is associated with glucose intolerance, abnormally low HDL (high density lipoprotein) high cholesterol and/or triglycerides, high blood pressure and upper body obesity. All of these factors are independent risk factors for coronary heart disease (CHD). CHD develops from a direct effect of insulin that stimulates lipogenesis in arterial tissue and enhances the growth of arterial smooth muscle promoting atherosclerosis. Increased insulin levels decrease fibrinolysis, increasing the risk for coronary thrombosis. Insulin also increases the hepatic production of triglycerides and lowers production of HDl (good cholesterol). High blood pressure may also be caused from the elevated insulin's effect on renal sodium reabsorption. Weight loss is a major benefit to those with Insulin Resistance Syndrome. High dose vitamin E has been reported to improve insulin resistance in type 2 diabetic patients. Zinc, selenium and vitamin C have been associated with decreasing oxidative stress in diabetic patients.

Impaired glucose tolerance (lGT) and impaired fasting glucose (lFG) are considered to be pre-diabetic conditions, and studies suggest that they may be reversible. IGT results from Insulin resistance covered in the above section.

IGT is a condition in which the blood glucose level is elevated (between 140 and 199 milligrams per deciliter or mg/ dl in a 2-hour oral glucose tolerance test), but is not high enough to be classified as diabetes.

IFG is a condition in which the fasting blood glucose level is elevated (between 110 and 125 mg/ dl after an overnight fast), but is not high enough to be classified as diabetes.

Among U.S. adults 40 to 74 years of age, 16 million (15.6 percent) have IGT and 10 million (9.7 percent) have IFG.

Stroke - The risk for stroke is 2 to 4 times higher among people with diabetes.

High blood pressure - About 73 percent of adults with diabetes have blood pressure greater than or equal to 130/80 mmHg or use prescription medications for hypertension.

Blindness - Diabetes is the leading cause of new cases of blindness among adults 20 to 74 years old. Diabetic retinopathy causes from 12,000 to 24,000 new cases of blindness each year.

Kidney disease - Diabetes is the leading cause of treated end-stage renal disease, accounting for 43 percent of new cases. In 1999, 38,160 people with diabetes began treatment for end-stage renal disease, and a total of 114,478 people with diabetes underwent dialysis or kidney transplantation.

Nervous system disease - About 60 to 70 percent of people with diabetes have mild to severe forms of nervous system damage. The results of such damage include impaired sensation or pain in the feet or hands, slowed digestion of food in the stomach, carpal tunnel syndrome, and other nerve problems. Severe forms of diabetic nerve disease are a major contributing cause of lower-extremity amputations.

Amputations - More than 60 percent of non-traumatic lower-limb amputations in the United States occur among people with diabetes. From 1997 to 1999, about 82,000 non-traumatic lower-limb amputations were performed each year among people with diabetes.

Dental disease - Periodontal or gum diseases are more common among people with diabetes than among people without diabetes. Among young adults, those with diabetes are often at twice the risk of those without diabetes. Almost one third of people with diabetes have severe periodontal diseases with loss of attachment of the gums to the teeth measuring 5 millimeters or more.

Complications of pregnancy - Poorly controlled diabetes before conception and during the first trimester of pregnancy can cause major birth defects in 5 to 10 percent of pregnancies and spontaneous abortions in 15 to 20 percent of pregnancies. Poorly controlled diabetes during the second and third trimesters of pregnancy can result in excessively large babies, posing a risk to the mother and the child.

Other complications - Uncontrolled diabetes often leads to biochemical imbalances that can cause acute life-threatening events, such as diabetic ketoacidosis and hyperosmolar (nonketotic) coma. People with diabetes are more susceptible to many other illnesses, and once they acquire these illnesses they often have a worse prognosis than people without diabetes. For example, they are more likely to die with pneumonia or influenza than people who do not have diabetes.

Research studies in the United States and abroad have found that lifestyle changes can prevent or delay the onset of type 2 diabetes among high-risk adults. These studies included people with IGT and other high-risk characteristics for developing diabetes. Lifestyle interventions included diet and moderate intensity physical activity (such as walking for 21/2 hours each week). For both sexes and all age and racial and ethnic groups, the development of diabetes was reduced 40 to 60 percent during these studies that lasted 3 to 6 years.

Studies have also shown that medications have been successful in preventing diabetes in some population groups. In the Diabetes Prevention Program, a large prevention study of people at high risk for diabetes, people treated with the drug metformin (GLUCOPHAGE®) reduced their risk of developing diabetes by 31 percent. Treatment with metformin was most effective among younger, heavier people (those 25 to 40 years of age who were 50 to 80 pounds overweight) and less effective among older people and people who were not as overweight. There are no known methods to prevent type 1 diabetes. Several clinical trials are currently in progress.

Glucose control - Research studies in the United States and abroad have found that improved glycemic control benefits people with either type 1 or type 2 diabetes. In general, for every 1 percent reduction in results of A 1 C blood tests, the risk of developing microvascular diabetic complications (eye, kidney, and nerve disease) is reduced by 40 percent.

Blood pressure control - Controlling blood pressure can reduce cardiovascular disease (heart disease and stroke) by approximately 33 to 50 percent and can reduce microvascular disease (eye, kidney, and nerve disease) by approximately 33 percent. In general, for every 10 millimeters of mercury (mmHg) reduction in systolic blood pressure, the risk for any complication related to diabetes is reduced by 12 percent.

Control of blood lipids - Improved control of cholesterol and lipids (for example, HDL, LDL and triglycerides) can reduce cardiovascular complications by 20 to 50 percent.

Preventive care practices for eyes, kidneys, and feet - Detection and treatment of diabetic eye disease with laser therapy can reduce the development of severe vision loss by an estimated 50 to 60 percent. Comprehensive foot care programs can reduce amputation rates by 45 to 85 percent. Detection and treatment of early diabetic kidney disease can reduce the development of kidney failure by 30 to 70 percent.

Appropriate nutritional supplementation - Adding adequate amounts of high grade nutritional supplements shown to be of benefit in diabetes may help improve daily glucose control, stabilize carbohydrate metabolism and prevent further complications from diabetes due to the glycosylated end products caused by elevated glucose levels. 

Routine exercise - low glycemic index diet - Routine exercise directly helps improve glucose metabolism by increasing the activity of glucose transport protein, independent of the action of insulin. Combined with an appropriate low glycemic diet, exercise has been shown to be nearly twice as effective as a leading anti-diabetic medication. A recent study was halted prematurely due to the profound superior benefit of diet and exercise over the prescription medication. It would behoove practitioners and clinicians caring for diabetic patients not to underestimate the significant impact that diet and exercise has on diabetes morbidity. Too often health care providers neglect this all important aspect of care and education, unfortunately, to the patient's detriment !