We Know How to Prevent Diabetes, So Why Don’t We?

Back in 1996, Microsoft was promoting Windows 95 "Chicago." The Summer Olympics opened in Atlanta. General Motors released the EV1, the first production electric car. Our knowledge of Diabetes was expanding. 

Scientists with The Diabetes Prevention Program Research Group set out to answer two basic questions: 

          Does lifestyle intervention or treatment with metformin prevent or delay the onset of

     Type II Diabetes?

          Do these interventions differ in effectiveness, and does it differ with age, sex, or ethnicity?

A total of 3,234 patients at 26 centers at risk for but without diabetes were randomized to three groups: a Metformin Goup, an Intensive Lifestyle Intervention Group, and a Control Group.

         The Metformin Goup received standard lifestyle recommendations (NCEP Step 1 diet) and   meformin 850mg twice daily. 

         The Control Group received the same standard lifestyle recommendations and placebo.

         The Intensive Lifestyle Intervention Group received a 16 lesson curriculum covering diet, activity, and behavioral modification – NOT traditionally part of the standard lifestyle recommendations. It included goals of 7% weight loss and 150 minutes a week of physical activity.

The ground breaking results published in The New England Jounal of Medicine February 7, 2002 demonstrated that both Intensive Lifestyle Intervention and Metformin reduced the incidence of Diabetes in persons at risk. Interestingly, The Intensive Lifestyle Intervention was found more effective than Metformin and Standard lifestyle recommendations.

The breakdown was as follows:

11 new cases of Diabetes per 100 person years in the Control/Placebo Group.

7.8 new cases of Diabetes per 100 person years in the Metformin Group.

4.8 new cases of Diabetes per 100 person years in the Intensive Lifestyle Group.

Put another way, the number of people needed to treat to prevent one new case of Diabetes was 6.9 for the Intensive Lifestyle Group and 13.9 for the Metformin Group. For every 7 people who engaged in the Intensive Lifestyle program one person would NOT develop Diabetes. For every 14 people who took metformin one person would NOT develop Diabetes.

Intensive Lifestyle Intervention was more effective in older people, people with lower baseline glucose, and those with lower BMI. Metformin was more effective in younger people, people with higher baseline glucose, and those with higher BMI.

Much more data confirming the findings were published in the years after publication. Yet, seventeen years later it appears much of what we learned has only been slowly adopted by public health policy and primary care medicine.

The Centers for Medicare & Medicaid Services offered a glimmer of hope in March 2016. The Office of The Actuary issued a report stating expansion of the YMCA's Diabetes Prevention Program as a covered benefit WOULD NOT result in an increase in Medicare spending but would actually save money. Today, Medicare recipients can enroll with a CDC certified program.

Is it enough? Sadly – NO. In spite of reams of evidence based medicine published over the last 20 years only a minority of at risk people are aware of or encouraged to partake in such proven interventions.

It is time for change.

Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.

Knowler WC1, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM; Diabetes Prevention Program Research Group.

N England Journal of Medicine. 2002 Feb 7;346(6):393-403.

Recertification of the Medicare Diabetes Prevention Program Expansion
https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/Diabetes-Prevention-Recertification-2017-11-01.pdf

Medicare Diabetes Prevention Program (MDPP) Expanded Model

https://innovation.cms.gov/initiatives/medicare-diabetes-prevention-program/

Endocrine Disruptors: Plastic Water Bottles, The Great Garbage Patch, and Your Risk of Dia-besity

Plastic arguably has made the world a better place – in some very important ways. Plastic allows us  to preserve food, sterilize equipment, and create building materials or safety products (think baseball helmets.) Plastic is relatively inexpensive, … or is it?  Read on. . .

Plastic is generally NOT biodegradable. However, over time it will wear down into microscopic pieces. Much of it finds it's way to the world's oceans where it can release some potentially troublesome compounds (such as BPAs and PCBs.). The microscopic materials are consumed by plankton and microorganisms, which are then consumed by other organisms, and eventually further up the food chain – we Humans.

BPA and PCBs are two classes of compounds known as Endocrine Disrupting Chemicals.

EDCs are defined as “substances in our environment, food, and consumer products that interfere with hormone biosynthesis, metabolism, or action resulting in a deviation from normal homeostatic control or reproduction.” In 2009 The Endocrine Society published a Scientific Statement reviewing the supporting scientific evidence of effects of EDCs on reproduction, breast cancer, prostate cancer, thyroid disease, metabolism/obesity, and cardiovascular disease. There are literally thousands of known EDCs. They can be synthetic such as PCBs, DDT, DES, or dioxin, or natural compounds such as phytoestrogens.

EDCs may not only affect one individual but also the children and subsequent generations of that individual. This effect is not by way of genetic mutation but rather by affecting how genes are expressed (by DNA methylation and histone acetylation.) In other words, by way of epigenetic expression.

There is much debate on risk and significance of low dose exposure to BPA and EDCs in general. One of the problems is that it may take years or decades of exposure before the effects become apparent.

Can we, or should we, avoid using plastic?

.We can refuse a plastic shopping bag for purchase of a package of chewing gum. Avoiding the use of plastic for most other things may be fairly impractical and probably impossible. How we dispose of plastic when we are though with it is another matter. We can be smart about recycling not merely for the benefit of some rare species in a remote corner of the world, but for us now. It is estimated by

The CDC that 93% of Americans have BPA in their urine. I don't know about you, but I would like to avoid dealing with cancer, diabetes, thyroid, and prostate issues if possible. Certainly, I do not wish to gift the same to my children or grandchildren either.

References:

Diamanti-Kandarakis, Bourguignon, Giudice, Hauser, Prins, Soto, Zoeller, & Gore .

Endocrine-disrupting chemicals: an Endocrine Society scientific statement

Endocr Rev. 2009 Jun;30(4):293-342. doi: 10.1210/er.2009-0002

https://www.ncbi.nlm.nih.gov/pubmed/19502515

Maffini, Maricel & S Rubin, Beverly & Sonnenschein, Carlos & Soto, Ana. (2006). 

Endocrine disruptors and reproductive health: The case of bisphenol-A. Molecular and cellular endocrinology. 254-255. 179-86. 10.1016/j.mce.2006.04.033.

 https://www.ncbi.nlm.nih.gov/pubmed/16781053

 

Le Corre L1, Besnard P, Chagnon MC.    

BPA, an energy balance disruptor. 

Crit Rev Food Sci Nutr. 2015;55(6):769-77. doi: 10.1080/10408398.2012.678421.                         https://www.ncbi.nlm.nih.gov/pubmed/24915348

BPA and Obesity in Children

Eng DS, Lee JM, Gebremariam A, Meeker JD, Peterson K, Padmanabhan V. 2013. 

 Bisphenol A and chronic disease risk factors in U.S. children. Pediatrics 132(3):e637-e645.

https://www.niehs.nih.gov/research/supported/sep/2013/bpa_obesity/index.cfm

Other Links:

E.P.A. Website:

https://www.epa.gov/endocrine-disruption/what-endocrine-disruption

N.I.H. Website:

https://www.niehs.nih.gov/health/topics/agents/endocrine/index.cfm

N.P.R. Story on  microplastics:

https://www.npr.org/sections/thesalt/2018/08/20/636845604/beer-drinking-water-and-fish-tiny-plastic-is-everywhere

THE EARTH IS FLAT???

THE EARTH IS FLAT???

The scientific community has accepted a round earth since the times of ancient Greece. 

Yet many well meaning people still believe maintaining a healthy weight is ONLY

 about balancing calories in (food) with calories out (exercise.)

Copyright foodandhealth.com, reprinted with permission

BUT, nothing in life is so neat and tidy.

We have learned much over the last two decades. Yet, years of peer reviewed medical research published in major medical journals has not dispelled "what we know."

Obesity is a Disease.

 This is not simply a matter of political correctness. Food intake and physical activity are important factors, but not the ONLY factors. Why is this so? A number of physiologic processes regulate the balance of the scale. Eat more calories and metabolism speeds up (to a point.) Eat fewer calories and metabolism slows down.  The body wishes to stay in balance. We know this state as homeostasis. We are our healthiest when homeostasis is maintained throughout.  When the balance is upset we can develop disease.

Hormones.

One of the most powerful physiologic controls is endocrine, or hormonal regulation.

  Hormones are chemical messengers made in one group of cells that travel to other cells to deliver a signal. Just about every hormone has a hormone twin that does the opposite function. A good example is Insulin which allows cells to take glucose up from the blood and Glucagon which releases glucose into the blood from glycogen stored in the liver. 

 Hormones tell us we are hungry or  full; and regulates how fast our metabolism "burns" calories. Few would argue a slow thyroid can lead to gaining unhealthy weight.

Are there other hormones that influence metabolic rate?

Yep. You betcha. Meet our friend Leptin. Leptin is released from the largest endocrine (hormone producing) gland in the body - adipose tissue (fat cells.) When adipocytes decrease in size (because we have lost fat) they release less Leptin. The appetite and metabolic centers in the brain interpret this as a sign - if we don't act we will starve!  
A survival response kicks in - and the rate of metabolism slows while appetite increases. Great when you are a contestant on Naked and Afraid; not so good when you are trying to lose weight and prevent Type II Diabetes.To add insult to injury, the appetite center in the brain may experience Leptin resistance. So adipocytes are sending Leptin, it is knocking on the door, but the receptor cells are not hearing it. Oh no, need to slow our metabolism down – we're starving! Not.

Ghrelin is another powerful hormone that stimulates appetite and regulates metabolism. While Leptin is more involved with long term survival regulation, Ghrelin regulates short term needs. Ghrelin cells are found mainly in the stomach, although also in other areas of the body. Ghrelin levels increase when the stomach is empty and decrease as the stomach stretches. It has been shown that baseline levels stay elevated after successful weight loss. Thus, Ghrelin is stronger than our friend Will Power. (Most people believe Mr. Power is an elusive fellow, but now you know the truth.)  Interestingly, many of the Ghrelin producing cells in the stomach are removed with Bariatric Surgery. We have since learned patient who have had Roux-en-Y gastric (RYGB) bypass have lower circulating levels than medically managed patients and have an easier time maintaining a healthier weight. About a decade ago The American Society for Bariatric Surgery changed it's name to American Society for Metabolic and Bariatric Surgery for this among other reasons. Although medications to inhibit Ghrelin have been investigated, Metabolic and Bariatric Surgery is currently the best treatment. More on that later.

Driving with the emergency brake on.

Sleep is restorative, and very necessary to maintain good health. Our bodies repair themselves while we are asleep. Growth in children occurs overnight with the release of Growth Hormone. Sleeping less than 7-8 hours a night? I bet you feel very tired during the day. Most you are likely burning fewer calories. It is more likely you will take the elevator rather than the stairs, park closer to the door, or defer other activities until you feel more rested. There is some evidence your Resting Metabolic Rate (calories burned while you are sitting quietly) is decreased due to your lack of sufficient or quality sleep, although this has not been a consistent finding.

 Other Factors.

There are a multitude of other factors known to influence unhealthy weight gain;

Type II Diabetes or family history of Type II Diabetes

Cardiometabolic Syndrome

Polycystic Ovarian Syndrome (which does not require ovarian cysts to diagnose!)

Cushing's Disease

Obstructive Sleep Apnea

Medications including over the counter agents (e.g. Benadryl.)

Stress and Anxiety

Inflammation

Gut Bacteria

MTHFR disorders

Genetics and Epigenetics

History of Tobacco, Alcohol, or Substance Use

Eating Disorders

History of Abuse

A good work up includes a comprehensive exam, labs to evaluate for the common, and the expertise to suspect the less common etiologies when appropriate. Each patient deserves an individualized work up and plan.  What may apply in one case may not in others, and  it is just about guaranteed to be a combination of factors for each person.

Obesity is a Chronic Disease … and it IS treatable.

Multidisciplinary treatment programs consisting of medical management of the problems stated above, nutritional education and support, physical activity which is appropriate for that individual, and behavioral support have demonstrated success time and time again. Yet, the commentary often comes back to weight regain when it ends. Imagine if we treat Hypertension as such. “Well congratulations on achieving a good blood pressure. You can stop treating it now.” It is NO DIFFERENT.

The time has come to stop repeating the same old tired Twentieth Century advice “eat less and exercise more” and realize that perhaps the correct advice for any particular  individual may be exactly the opposite. “Eat more (protein) and exercise less (as you are not consuming enough calories and triggering a slow metabolism/starvation response.)

Each person deserves an individualized evaluation and above all else the insight we are dealing with a disease and not a character flaw.

It is 2018.

It is time to join The Twenty First Century!