The latest statistics from the Centers for Disease Control and Prevention (CDC) reveal an eye-opening number: 24 million Americans are now living with diabetes -- 18 million have been diagnosed and 6 million have diabetes but they haven't yet been diagnosed. Statistics show that 90-95 percent of people with diabetes have type 2. Research studies and clinical trials are going on across the United States and around the world, sparking awareness, debate, and hope.
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At the Forefront of Diabetes Research
The U.S. government spends more than $1 billion a year on diabetes research. For close to 70 years, the American Diabetes Association (ADA) has dedicated its resources to research, educate, legislate, and fight for progress and against discrimination. The Juvenile Diabetes Research Foundation International (JDRF), founded in 1970 by parents of children with type 1 diabetes, is another influential organization dedicated to type 1 research and advocacy, including advancements in drug therapies and stem cell research.
Read on for updates on some of the biggest advances and findings in diabetes today.
An international expert panel now recommends the A1C test -- the measure of blood glucose over the past two to three months -- to diagnose diabetes in everyone except pregnant women. Until now, diabetes was diagnosed by checking fasting or random blood glucose.
Research revealed that while one or more blood glucose tests can just happen to be elevated, a high A1C is a surer bet that blood glucose has been high for some time and is slowly damaging the body.
Here's how A1C results are used to diagnose diabetes:
People at high risk (known as pre-diabetes) are encouraged to lose weight (10-20 pounds) and become more active (at least 150 minutes of physical activity each week). That's the best strategy scientists have found to prevent or delay the development of type 2.
Action item: Urge people you know who are older than 45 or at risk for diabetes to get an A1C blood test. The most reliable A1C test results are from a lab rather than on-the-spot results at a medical office or at home.
An A1C test reflects your average blood glucose level over the past two to three months, giving you a more complete picture of your blood glucose levels. Experts recommend getting the test at least twice a year if not four times a year. Find your A1C report confusing? Not sure how to relate your A1C of 7 percent to the readings from your daily monitoring with a blood glucose meter? You'll like the new approach health care providers are using to explain A1C: Estimated Average Glucose (eAG). The eAG translates your A1C into a number just like a meter reading. So your 7 percent A1C is 154 mg/dl using the eAG.
The American Diabetes Association hopes the eAG will help people with diabetes better understand their A1C results and give them another tool in managing their diabetes.
Action item: Ask your health care provider for an eAG along with your A1C results, then talk about what those results mean for your diabetes management and blood glucose control.
For weight loss and blood glucose control, modestly limiting carbohydrate intake may be the most sensible approach. New research identified by Marion Franz, R.D., CDE, a nutrition and diabetes consultant from Minneapolis, reinforces that people with diabetes (PWDs) benefit from moderate -- not low -- carb intake. (Definition of low-carb intake: Less than 45 percent of daily calories from carbohydrate sources.)
Type 2 diabetes: A large and lengthy weight loss study including PWDs type 2 had participants follow one of four similar diets. They showed maximum weight loss at six months and some weight regain after two years. Participants had a tough time reaching either the low- or high-carbohydrate goals. By the end of the study, however, most participants found it easy to lose weight when they consumed 43-53 percent of their daily calories from carbohydrate sources -- considered moderate carbohydrate intake.
Type 1 diabetes: A study analyzing the food intake of people from the intensively treated group of the Diabetes Control and Complications Trial showed that participants who had an average carbohydrate intake of 56 percent of daily calories had a significantly lower A1C (7.08 percent) compared with an A1C of 7.47 percent for participants whose average carbohydrate intake was 37 percent of daily calories.
"When individuals with diabetes reduce carbohydrate intake to a low level, they reflexively increase their intake of total fat, which often includes unhealthy saturated fats," Franz says. "Research shows long-term intake of fats contributes to insulin resistance, while eating carbohydrate from healthful sources improves insulin sensitivity."
Action item: Eating healthy carbohydrate, such as fruit, vegetables, and whole grains, is essential for living well with diabetes because it provides important vitamins and minerals your body needs to function. Work with a registered dietitian to define a moderate carbohydrate intake for you. Meal plans with less than 45 percent of daily calories from carbohydrate sources are tough to follow, may not assist with blood glucose control, and can make it difficult to get needed nutrients. To lose weight, aim to limit total calories rather than restrict specific nutrients.
Scientists at the University of North Carolina's Chapel Hill School of Medicine have successfully transformed human skin cells into insulin-producing cells. This innovation in cell reconstruction is a big step for the future of cell-base transplants. Scientists involved in this ongoing study hope to reduce the risk of rejection by using a person's own reprogrammed cells generated from their skin.
Action item: The groundbreaking study is a new approach to long-term insulin therapy for type 1 diabetes and offers hope for new treatments. Human trials are still a few years away. Keep an eye out for these studies and further results.
Findings from three major clinical trials strongly suggest that targeting blood glucose control early in diagnosis is a smart approach. The studies -- ACCORD, ADVANCE, and VADT -- looked at people who had lived with type 2 diabetes for an average of 10 years. Would intensive glucose control help prevent heart attacks and strokes in this group? Results are still reverberating, but it seems that heart events weren't greatly reduced by intense blood sugar control in people with long-term type 2 who are already at high risk for these problems. But that's no excuse to avoid tight control.
"Research on early implementation of tight control is accumulating and repeatedly shows control matters most in the first five years after diagnosis," says John Zrebiec, CDE, of the Joslin Diabetes Center in Boston. After many years of diabetes, however, targets may be slightly higher, says Connie Crawley, R.D., a dietitian with University of Georgia Extension. "If you've had type 2 upwards of 10 years and suffer from one or more complications, work with your provider to individualize your target numbers," she says.
Action item: Put your game plan in place and strive for excellent control of blood glucose, blood pressure, and blood lipids such as cholesterol from day one. If you've had diabetes for years and less-than-tight control, it's not too late to improve your numbers, but discuss safe blood glucose targets with your health care provider.
Researchers have found that people with diabetes have higher rates of hearing loss than people without diabetes. Scientists working with the National Institute on Deafness and Other Communication Disorders believe that damaged nerve and blood vessels in the ear are to blame for the hearing loss. The 2008 study found hearing loss across all frequencies, with high-frequency hearing loss being the most common in adults with diabetes who are 20-69 years old.
Action item: Risk of hearing loss is another good reason to be proactive in diabetes management to prevent future complications. If you experience any symptoms, such as difficulty hearing on the telephone or straining to hear a conversation, talk to your doctor about scheduling a hearing test.
Combination pills help reduce the number of pills you need to take. For example, Avandamet is a combination of Avandia (rosiglitazone) and metformin. Some combination pills incorporate high blood pressure or high cholesterol medication as well. Combination pills are considered a second-line therapy by the U.S. Food and Drug Administration, so they are not recommended if you are newly diagnosed with type 2 diabetes, says Marty Irons, R.Ph., CDE, a pharmacist and member of the Diabetic Living advisory board.
"So many people with type 2 balance six to 12 medications daily in multiple doses," Irons says.
Action item: To find out if combination pills are right for you, Irons recommends taking these steps:
- Talk to a pharmacist about your current medications and whether a combination pill that meets your needs and doses is available.
- Check with your health plan about policies on covering combination pills. Make sure you're covered.
- Talk to your doctor about switching your prescription. If you adjust your dosages frequently, combination pills are probably not for you.
The abundance of salt in the processed foods we eat works against us when it comes to maintaining healthy blood pressure, says Chris Smith, The Diabetic Chef. For people with diabetes, controlling blood pressure is important in preventing, delaying, and minimizing microvascular damage that affects eyes, nerves, and more.
That's why federal guidelines for daily sodium intake are under scrutiny. The recommendations are:
For the general public: 2,300 milligrams daily
For people with high blood pressure: 1,500 milligrams daily
For African-Americans: 1,500 milligrams daily
For all adults over age 50: 1,500 milligrams daily
Yet nearly all Americans exceed the recommended amounts, consuming an average of 4,000-6,000 milligrams of sodium each day. An estimated 70 percent of Americans, especially older adults and people with high blood pressure (75 percent of PWDs have high blood pressure), could lower their blood pressure by reducing their sodium intake to 1,500 milligrams each day.
"Help is on the way as food manufacturers and restaurateurs are being nudged by health organizations and activists to lower the sodium count of their foods," Smith says. Early deliberations from the 2010 Dietary Guidelines Committee (the report is expected in fall 2010) indicate a target of 1,500 milligrams daily for adults.
Action item: Cut down on processed foods, restaurant foods, and using the saltshaker. Eat more fruits, vegetables, and low-fat dairy foods, which boost your potassium count and blunt sodium's effects on blood pressure.
Women who are diagnosed with gestational diabetes (also called GDM) during pregnancy have a much higher risk of developing type 2 diabetes during their lifetimes. Their children also have an increased risk for obesity and type 2 diabetes. According to the National Institutes of Health, about 7 percent of pregnancies, or about 200,000 expectant mothers, are affected by GDM every year.
Action item: The silver lining to this troublesome statistic is that the risk to both mother and child is preventable. The National Diabetes Education Program has launched a campaign, "It's Never Too Early to Prevent Diabetes," to inform new and expectant mothers. Use these tips to help reduce your risk:
- Reach a healthy weight before you conceive. Being overweight increases your risk for type 2 diabetes as well as gestational diabetes.
- Get tested for type 2 diabetes 6-12 weeks after your baby's birth, and then every one to two years after that.
- Achieve your prepregnancy weight 6-12 months after giving birth. If you are still overweight, losing 5-7 percent of your body weight can prevent or postpone the onset of diabetes.
- Breast-feed your children to reduce their risk for diabetes.
- Follow a healthy eating plan, which helps you lose some weight, and choose healthy, lower-fat foods.
- Be a role model for your new child and other children in your family by serving healthy meals and snacks.
- Increase physical activity and exercise to at least 30-60 minutes a day for the whole family.
"We now know that type 2 is a progressive disease that requires serious attention from day one," says Virginia Valentine, R.N., CDE, PWD type 2, a clinical nurse specialist and co-owner of Diabetes Network, Inc., in Albuquerque, New Mexico. Mounting evidence shows that early, aggressive management of blood glucose can make caring for type 2 easier down the road. The push is on to treat type 2 diabetes aggressively from day one.
The American Diabetes Association and the European Association for the Study of Diabetes recommend: Adults diagnosed with type 2 diabetes immediately start the medicine metformin, which combats insulin resistance.
The goal: To stabilize the insulin-producing beta cells in the pancreas and keep them alive longer to slow the progression of type 2.
Why it's important: Mounting evidence shows that aggressive lowering of blood glucose in newly diagnosed diabetes, especially with the use of insulin, can slow the dwindling of beta cells.
Research shows that people with early-onset diabetes who target tight control early in the diagnosis can more easily control their blood glucose with less medication for a longer time. People who have years of inadequately controlled blood glucose have more difficulty gaining control and use more medicine.
Action item: These results show that the earlier blood glucose medications are begun after diagnosis, the better it is for blood glucose control and long-term health. If you have just been diagnosed with type 2 diabetes, talk with your doctor about whether blood glucose medication can help you.
A new study of islet cell transplantation is investigating ways to prolong function of insulin-producing islets after transplant and decrease antirejection drugs' side effects, which can include infection and damage to nerves and kidneys.
The new strategy cultures islets before transplantation to improve insulin production and compares antirejection drugs and their influence on donor islets. In an islet transplant, clusters of insulin-producing beta cells that live in islets are taken from a donor pancreas and implanted in the recipient's liver to make insulin.
Action item: If the clinical trials regarding antirejection therapies are successful, researchers could seek U.S. Food and Drug Administration approval for the improved procedure in type 1 patients who have significant difficulty controlling blood glucose or who experience severe episodes of hypoglycemia. Check out the two links below to find out more information on islet transplantation and clinical trials.
With the right support, weight loss is possible. And it's not just for looks -- losing 10-20 pounds improves blood glucose control and may decrease risk of heart and blood vessel disease and diabetes complications. James O. Hill, Ph.D., professor of pediatrics and medicine at the University of Colorado Denver Health Sciences Center, identified the interim results of the Look AHEAD (Action for Health in Diabetes) trial funded by the National Institutes of Health.
The trial is investigating whether losing weight soon after being diagnosed with type 2 can decrease the amount and severity of heart and blood vessel disease in the long term. "The trial has shown that weight loss using intensive and continuing support, meal replacements, and physical activity can be achieved and maintained (albeit with some weight regain over the years) even if people are older, sicker, and have had the disease longer," Hill says. "Though it's still too early to tell, the impact on reducing heart and blood vessel disease is promising."
Action item: Losing a small amount of weight (10-20 pounds) early in the course of type 2 diabetes and keeping it off can improve blood glucose control and prevent or delay heart disease, even if you regain some of the weight later.
Weight Loss Tips that Work:
The Harvard University-based Nurses' Health Study showed that women who closely followed the Mediterranean diet, which includes whole grains, nuts, fish, olive oil, and moderate amounts of alcohol, averaged 23 percent higher blood levels of a hormone called adiponectin than women who did not follow the diet closely. Adiponectin works as an insulin sensitizer and can be found in Mediterranean-style foods, such as olive oil.
Action item: To reap the benefits of a Mediterranean diet, use these tenets of Mediterranean-style eating as you make your meal plans:
- Eat daily: Whole grains, starchy and nonstarchy vegetables, fruits, nuts, olive oil, and yogurt as well as wine in moderation
- Eat weekly: Fish, chicken, eggs (up to four per week), and sweets as permitted in your meal plan
- Eat monthly: Red meat
Continuous glucose monitoring is the future for keeping track of your body's glucose levels. (Currently it's primarily accessible to people with type 1 diabetes.) The continuous glucose monitor (CGM) is a sensor under your skin that gives you a glucose number every few minutes, adding up to hundreds of readings a day. If the CGM detects a high or low reading, it sends an alert to your receiver, warning you of impending trouble. These alerts can help you take action to control highs and lows.
Working with your diabetes educator or health care provider, you set up the receiver with your desired high and low thresholds to detect your personal glucose boundaries. The receiver also details glucose trends and how quickly -- or slowly -- glucose levels are changing in your body. Plus, the CGM stores all of your data for later analysis on your computer or online with company-specific data-management software.
Action item: To truly benefit from continuous glucose monitoring, you must be willing to take a very active role in managing your diabetes.
"We've found if people don't invest time in training, they get frustrated and may discontinue using their CGMs," says Alison Evert, M.S., R.D., CDE, of the University of Washington in Seattle. "Follow-up visits with a diabetes educator are key to getting the most from your device."
Pharmaceutical companies are turning to the gut in their search for the next blockbuster blood glucose-lowering drug. "Researchers have discovered a group of intestinal hormones called incretins, which PWDs tend to be deficient in," says pharmacist Marty Irons. "Incretins are involved with controlling the rise of blood glucose after eating, a problem for many PWDs."
Today there are two classes of medications that focus on intestinal hormones. In the injectable incretin mimetic category is exenatide (Byetta), which must be injected twice a day. Research on liraglutide (Victoza), a once-daily injection, is still under way, and the drug may not reach the market due to a side effect. Other incretin mimetics are under development, including a once-a-week form of slow-release exenatide that's under review by the U.S. Food and Drug Administration.
The second class of medications is oral dipeptidyl peptidase IV (DPP-4) inhibitors, which slow the breakdown of the gut hormone to let it remain active longer and lower blood glucose levels. These drugs, including sitagliptin (Januvia) and the newly approved saxagliptin (Onglyza), may also assist in weight loss.
Action item: Ask your provider about medications that help with blood glucose and weight targets.
More people are diagnosed with type 2 diabetes each year. Why? Experts point to rising obesity rates as a main culprit of type 2 diabetes, along with sedentary lifestyle, aging, and an increase in populations with a high incidence of diabetes.
Diabetes affects every state in the country. A new Centers for Disease Control and Prevention (CDC) map identifies high-risk diabetes populations by U.S. counties. The county-by-county breakdown can help state and local governments determine the need for resources to target areas most affected by poverty or lack of education.
Some racial and ethnic groups are more affected by diabetes than others. This breakdown by the CDC shows diabetes diagnosis rates adjusted for population age for racial and ethnic groups in the United States.
Native Americans and Alaska Natives: 16.5 percent
African-Americans: 11.8 percent
Latinos: 10.4 percent
Asian-Americans: 7.5 percent
Whites: 6.6 percent
Action item: Find out if you or someone you love is at risk for type 2 diabetes by getting your blood glucose tested. The earlier diabetes is diagnosed, the earlier treatment can begin and the better your chances of avoiding diabetes-related complications.