Diabetes: Prevention, Treatment & Maintenance
I. General description of Diabetes:
When we eat food our body breaks it down into glucose, a form of sugar that the body uses as a form of energy. The pancreas, an organ that lies near the stomach, produces the hormone insulin which facilities the cells to take up glucose. Diabetes causes the body to produce too little insulin or does not allow the cell to use the existing insulin as well as it could. As a result blood sugar levels increase.
Defects in the ability of a target cell to produce, release or uptake insulin results in diabetes mellitus, which is a condition where the blood glucose levels are high and vary greatly with sugar intake. One of the major health concerns with diabetes is high lipid and cholesterol levels circulating in the blood. The reason is that since the body cannot rely on insulin it must compensate by relying more heavily on fats. The result of this alternative is fat deposits in the blood vessels leading to high blood pressure and heart disease. Diabetes it the third leading cause of death in the United States.
There are two major forms of diabetes mellitus:
Insulin-dependent or juvenile-onset diabetes mellitus, which most often strikes suddenly in childhood (Type 1)
Insulin dependent diabetes is the result of a deficiency in the pancreatic beta cells, which results in insulin being absent or nearly absent. Those who suffer form this type of diabetes require daily insulin shots and are restricted to careful diet and exercise programs. As a result of the disease an individual with this form of diabetes has a life span that is reduced by one third as a result of kidney malfunction, nerve impairment and cardiovascular disease that is a direct complication of the disease. The hyperglycemia (high blood [glucose]) of diabetes mellitus also leads to blindness through retinal degeneration and the glucosylation of lens protein, which causes cataracts. 1 Insulin dependent diabetes has a rapid onset because of the autoimmune attack on the pancreatic beta cells. The full onset and symptom of the disease only occur after approximately 80% of the beta cells have been destroyed.
This form of diabetes accounts for approximately 5% - 10% of all diagnosed cases of diabetes. The risk factors include genetic predisposition, autoimmune and environmental factor that play a major role in its development.
Non-insulin dependent or maturity-onset diabetes mellitus, which usually develops gradually after the age of 40
Non-insulin dependent diabetes (Type II) accounts for approximately 90% of the diabetes in the population. This form of diabetes occurs mostly in obese individuals and those who have a genetic predisposition for the condition. Their cells are said to be insulin resistant because the insulin receptors on the cells are no longer responsive, which causes blood glucose level to be very high. There is believed to be a genetic mutation in the insulin receptor that is associated with non-insulin dependent diabetes, and occurs in approximately 5% of the diagnosis. There are many factors that work in concert to lead to the development of type II diabetes. The risk factors are very well characterized and include age, obesity, family history, physical inactivity and race/ethnicity. 
There is a rare form of non-insulin dependent diabetes called maturity-onset diabetes of the young (MODY).1 The onset of this form of diabetes occurs around the age of 25 and results from a mutation in an enzyme.
Gestational diabetes occurs on approximately 2%-5% of all pregnancies and usually disappears after pregnancy. This type of diabetes appears more frequently in African American, Hispanic and American Indian women and those with family histories of diabetes. Those women who have had gestational diabetes have an increased risk of developing type 2 diabetes later in life. About 40% of those women who develop gestational diabetes will develop the disease later are several symptoms of diabetes:
Common symptoms and current treatment of Diabetes:
♦Unexplained weight loss
♦Sudden vision change
♦Tingling or numbness of the hand and feet
♦Very dry skin
♦Sores that are slow to heal
♦More infections than usual
There are treatments available for each different form of diabetes. For type I, in which there is a lack of insulin production, treatment is difficult to regulate. Treatments include a carefully planned diet, physical activity, blood glucose testing several times a day and insulin injections. Effective treatment of Type 2 includes controlled diet, exercise, blood sugar level testing, and in some cases insulin injection. Approximately 40% of individuals that have Type 2 require daily insulin injections.
Regular physical activity has been shown to significantly reduce the risk of developing Type 2. Several studies have shown that physical activity helps in the prevention and control of diabetes. Obesity has also been shown to be a big contributor of type 2 onset. Even thought diabetes does not have a cure; those working to prevent diabetes have three approaches to prevention and a possible cure: prevent diabetes’s cure diabetes; and take better care of people with diabetes to prevent complications. 
There are several approaches to a “cure” are currently being pursued:
Islet cell transplantation (islet cells produce insulin)
Artificial pancreas development
Genetic manipulation (fat of muscle cell that don’t normally make insulin have a human insulin gene inserted – then these “pseudo” islet cells are transplanted into people with type 1 diabetes.
Occurrence of Diabetes in America:
There are approximately 1.6 million Americans who have diabetes, which accounts for 6% of the population. There are approximately 6.4 million Americans who do not know that they have the disease and are not taking important preventative measures. Each year nearly 800,000 people are diagnosed with diabetes, and the number of those diagnosed has risen from 1.5 million in 1958 to 10.3 million diagnosed in 1997, this is a 6-fold increase in the incidence. Of those diagnosed, Type 1 accounts form only 5-10% of the cases where as Type 2 accounts for 90-95% of all the cases. Diabetes is the seventh leading cause of death in the United States, it accounted for approximately 187,800 deaths in 1995. The death rate is approximately two times as high in middle-aged people with diabetes as those of the same peer group without diabetes.
Prevalence by gender:
7.5 million men ages 20 and older have diabetes, while 8.1 million women 20 or over have been diagnosed with diabetes.
Prevalence by age:
6.3 million Americans 65 or older have diabetes which accounts form approximately 18.4% of this age group.
8.1 million Americans age 20 or older have diabetes, which is approximately 8.2% of this peer group.
Occurrence by Race:
Approximately 2.3 million African Americans have diabetes, this accounts for about 10.8% of this ethnic group. It has been found that African Americans are 1.7 times as likely to have diabetes than their Caucasian peers.
The Hispanic population is two times as likely to develop diabetes as their Caucasian peers.
Asian Americans & Pacific Islanders:
The data for this section of the American population varies greatly, so sub groups within this ethnicity are more likely to develop diabetes while other run a lower risk of developing the disease. The Native Hawaiians were found to be twice as likely to be diagnosed with the disease compared to the Caucasian residents of the Hawaiian Islands.
Within the Native American population, the rate of diabetes varies greatly among the tribes and villages varying any where from 5 – 50 percent of the population.
Approximately 11.3 million non-Hispanic whites have diabetes, that is about 7.8% of the Caucasian population.
Geographic occurrence of diabetes:
The occurrence of diabetes is most prevalent in the southern portion of America. :
In Mississippi, 17% of adults ages 65-74 have diabetes – the highest prevalence in the United States for this age group. In addition, 8.5 % of adults ages 45-64 in Mississippi have diabetes. 
In Texas, 15.2% of adults ages 65-74 have diabetes – the second highest prevalence in the United States for this age group. In addition, 9% of adults ages 45-64 in Texas have diabetes. 5
In Alaska, Delaware, Louisiana, Pennsylvania, and South Carolina, approximately 14% of adults ages 65-74 have diabetes. 5
The goal of primary prevention is to reduce the risk factors and increase healthy behavior that helps prevent or delays the onset of diabetes. These preventative steps include encouragement of physical activity, achieving and maintain a healthy weight. This type of treatment is most successful when implemented in childhood and to early adulthood, were healthy habits will increase the years of life free of disease and without complications. Some states that currently have successful diabetes prevention programs in place are:
The Minnesota Diabetes Prevention and Control Program has teamed up with a large local health plan to improve diabetes care at primary care clinics. Patients’ blood glucose levels, cholesterol levels, and quality of care have improved significantly since the 1994 launch of Project IDEAL (Improving Diabetes through Empowerment, Active collaboration, and Leadership). As a result, participants’ risk for diabetes-related heart problems has declined 40%, and their risk for eye and kidney disease has declined 25%. Patients are also far more likely to have annual exams known to prevent blindness, kidney failure, and amputation. 
The California Diabetes Prevention and Control Program assessed the effects of case management on blood glucose levels among Medicaid patients. Blood glucose levels had declined significantly at 18 months among patients who received diabetes care guidelines, blood glucose monitoring instruction, and nutrition education in addition to usual care. Improved glucose control decreased their risk for complications and cut health care costs. 6
The New York Diabetes Prevention and Control Program works with many partners to improve diabetes care. In 2 years, provider- and community-focused interventions have reduced rates of diabetes hospitalization by 35% and rates of foot and leg amputation by 39%.6
The results of a Finnish study show that lifestyle changes can reduce the risk of progression toward diabetes by 50% over a four-year period.  The study included 522 middle aged, overweight individuals who already had impaired glucose tolerance. Individuals in the study received counseling that was aimed at reducing weight, improving diet, reducing the intake of total fat, saturated fat, increasing daily fiber intake, and increased daily physical activity. The results of this study clearly demonstrates the appeal of lifestyle changes, they are inexpensive, have very few side effects and are very effective in reducing the factors that are associated with diabetes. Lifestyle changes not only decrease the risk factors for diabetes but also resulted in a reduction in blood pressure and cholesterol levels.
Secondary preventive measures are focused on detecting possible cases of diabetes through the use of screening programs. There is a difference between performing diagnostic tests and screening for diabetes. The goal of screening is to identify individuals who do not show symptoms but have a likelihood of developing the disease because of life style, family history.  There are seven guidelines that determine if screening for a particular disease is warranted in a community, they include:
2. The natural history of the disease is understood
For diabetes, conditions 1-4 are met. Based on these guidelines and findings the American Diabetes Foundation has made the following recommendation about community screenings below:
“The effectiveness of screening may also depend on the setting in which it is performed. In general, community screening outside a health care setting may be less effective because of the failure of people with a positive screening test to seek and obtain appropriate follow-up testing and care, or conversely, to ensure appropriate repeat testing for individuals who screen negative. That is, screening outside of clinical settings may yield abnormal tests that are never discussed with a primary care provider, low compliance with treatment recommendations, and a very uncertain impact on long-term health. Community screening may also be poorly targeted, i.e., it may fail to reach the groups most at risk and inappropriately test those at low risk (the worried well) or even those already diagnosed”. 3
Effective treatments and prevention programs for diabetes are in place but the CDC found are used less than recommended. In order to increase the number of individuals who get preventative care, the CDC has implemented the national health objective for 2010. The goal of this initiative is to increase the preventative care that those with diabetes participate in. These measures include: eye examinations, foot examinations, self-monitoring of blood glucose, influenza vaccines, and pneumonococcal vaccinations.
The Journal of American Medical Association published a study entitled, The Cost-effectiveness of Screening for Type 2 Diabetes. “The goal of this study was to estimate the cost effectiveness of early detection and preventative treatments of type 2 diabetes”.  By early diabetes screening, public health officials can implement programs that will help decrease the future incidents and help to prevent future health complications in those who suffer from diabetes. “If early treatment of type 2 diabetes reduces the incidence or slows the progression of major complications, it might sufficiently reduce the costs of treatment during later years to offset the costs associated with screening and early treatment”. 9 Early screening programs involve testing serum glucose, determining serum insulin levels using radioimmunoassay and total cholesterol levels. These screenings can be done during routine doctor’s visits. By implementing this program, the cost of the routine office visit will increase since this will take more of a physician’s time and more laboratory expenses. The JAMA study found that by screening all adults “aged 25 years or older decreased the average age at diagnosis by 6 years. The lifetime cumulative incidence of ESRD (end stage renal disease), blindness, and LEA (lower extremity amputation) are reduced by 26%, 35%, and 22%, respectively, and years of life without major complications are increased”. 9 Even thought diabetes is not prevented, the prevention of major complications saves the health care industry money in the long run. It is most cost effective to screen younger adults, since they can gain the most life-years free from complication. Within this group the greatest gain was made in the prevention of blindness, which was reduced by approximately 7.5%. It was found that the major benefits of screening and preventative treatment occur in the postponement of complication and the improved quality of life. “Although the cost per case detection was higher among younger adults, these extra costs are more than offset by the reduced costs form lifetime complications prevented”. 9
The ethnic group that was found to benefit the most form preventative screening was the African American community. “The model estimates savings of $5539 in the lifetime costs of treatment among African Americans aged 25 to 34 years compared with $1275 among all other races”.  The results of a national study found that when “compared to their white counterparts, African Americans men are 20% to 50% more likely and African American women more than 100% more likely to have or to develop diabetes”.  One of the hypothesized reasons for these racial differences is the increased rate of diabetes risk factors present included very little physical activity, low socioeconomic status, and an increase in family prevalence. This study found that African American women had higher blood pressure, levels of insulin and HDL cholesterol than their white peers. 10 Based on these findings screening programs would be most beneficial in African American communities.
The major result that was gleaned from the study was that contrary to the American Diabetes Association recommendation for screening to being at age 45, it is more cost effective to screen younger adults for type 2 diabetes.
The goal of tertiary treatment is to prevent or deal with complications that are associated with diabetes. This form of treatment is implemented after diagnosis has been made, with the goal to control the disease. The major form of tertiary treatment it monitoring of blood glucose levels, screening for diabetic retinopathy, foot lesions, nerve damage, and protein in the urine (a sign of possible kidney damage).
One of the most important treatments that diabetics can do is to take care of the feet and lower extremities. Individuals with diabetes are fifteen times more likely than those who do not have diabetes, to have lower extremity amputations (LEA). The main reason for lower extremities is that as a result of diabetes, nerves in the lower extremities are damaged and therefore results in the loss of “protective” sensation. The American Orthopeadic Foot and Ankle Society conducted a study to determine why there is such a high in incidence of LEA in individuals with diabetes. It was found that even though patients who had diabetes knew the potential for diabetic foot morbidity, more than half did not take advantage of the preventative available such as prophylactic protective foot wear.
Another tertiary treatment for diabetes is dialysis, which is done once total kidney failure has occurred as a result of poorly/unregulated diabetes. One in five people who have diabetes treated with insulin or diet will develop kidney failure. Kidney failure is a result of damage to the blood vessels in the kidney, which results in poor filtration of the blood by the kidneys. High blood pressure and increased glucose levels are the primary causes of kidney failure in individuals affected with diabetes. Those who develop kidney failure also experience eye problems, poor circulation and/or heart disease. It is very important to monitor for signs of kidney failure so that before it occurs measures are taken so that the patient can start dialysis immediately. There are several steps that should be taken to prevent kidney disease:
Control blood glucose levels, keeping blood pressure levels with in the normal healthy range, maintain a healthy diet and always keep physician appointments are the best ways to prevent kidney failure. 
The American Diabetes Association has a web page that lists the Standards of care that each patience who is diagnosed with diabetes should adhere to. The web address is:
Diabetes is often not diagnosed until complications begin to appear, and one third of people who have diabetes are undiagnosed. There are three areas where diabetes can be prevented or treated, the primary, secondary and tertiary level. The most effective level is at the primary level, because at this level not only is diabetes treated but also high blood pressure and cholesterol. Even thought diabetes has no cure, it is preventable and treatable with diet and exercise. This is a world wide epidemic that can be treated effectively and economically. The results of several studies show that the best screening techniques are those where communities and primary health services work in concert.
 Fundamentals of Biochemistry: Voet, D; Voet J; Prett, C. John Wiles & Sons, INC New York 1999
 Behavioral Risk Factor Surveillance System, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1993-1995.
 Diabetes Care 26:S21-S24, 2003
 BMJ article
 Screening for Type 2 Diabetes (Position statement) , Diabetes Care 26:S21-S24, 2003
 The Cost-effectiveness of Screening for Type 2 Diabetes Journal of American Medical Association 1998 November 25; 280(20) 1757-1763.
 Incident Type 2 Diabetes Mellitus in African American and White Adults Journal of American Medical Association 200 May 7; 283(17) 2253-2259.