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Taking Control of Pre-Diabetes by Wenda Reed

Say you’re shoveling coal into a boiler that runs a steam train. The train isn’t going anywhere, so the coal isn’t being used to power the locomotive. The boiler is already full, but you keep on shoveling. The engineer keeps turning up the heat in the boiler to burn all that coal, but eventually the machine can’t keep up and starts to break down.

This is a very simplified description of what happens to a person with diabetes or pre-diabetes.
Dr. Matthew Davies, an endocrinologist at Swedish Medical Center, puts it this way. We are living a relatively sedentary lifestyle. We have a high calorie/high carbohydrate diet. This means we are “trying to stuff sugar and other carbohydrates into muscles that are already full.” We need more of the hormone insulin to help glucose (digested sugars and carbohydrates) enter the cells and be used for energy. “Eventually, the pancreas can’t make all of the insulin the person needs and begins to wear out,” Davies says.

The pancreas either ceases to produce enough insulin or the body ceases to use the insulin correctly (insulin resistance). Glucose then builds up in the bloodstream where it can be measured with blood tests. A person with high levels of blood sugar is diagnosed with type 2 diabetes. A person with blood sugar levels higher than normal, but not as high as the threshold for full-blown diabetes, has pre-diabetes.

Diabetes is a train wreck for the body. The excess glucose can attach to proteins in the blood vessels and alter their normal structure and function. One effect of this is that the vessels become thicker and less elastic, making it hard for blood to squeeze through. If blood sugar levels are not controlled, a diabetic person is two to four times more likely to suffer heart disease or stroke than a person with normal blood sugar. She is more susceptible to blindness, kidney disease, nerve damage and circulatory problems, which, in the worse case, can lead to infections and amputations.

It is a disease to be avoided at all costs, and yet its incidence has been steadily rising, in tandem with a rise in the number of people who are overweight or obese. Presently, 23.6 million Americans — about 7.8 percent of the population — have diabetes.
This doesn’t sound so bad until we consider three other statistics:

• One in three Americans born in the year 2000 will develop diabetes if current trends continue, according to a U.S. Centers for Disease Control and Prevention (CDC) report.
• 54 to 57 million of us — that’s one in four adults — have pre-diabetes. This level has risen over the past 20 years, partly because more of us are overweight and partly because guidelines have become stricter.
• People with pre-diabetes are five to 15 times more likely to develop diabetes than the general population, depending on their genetic makeup. For many people, it will occur within 10 years.

The good news is that “progression to diabetes in not inevitable,” according to the CDC. The onset can be delayed or even prevented. In comparison with many diseases, “the patient with pre-diabetes or diabetes has a lot of control,” says Dr. Paul Anderson, a Seattle naturopath and associate professor of pharmacology and clinical medicine at Bastyr University. He is a diabetic and has been able to “step back” from dependence on insulin and drugs through diet and exercise.

The experts we talked to all repeated the same statistic from the landmark 2002 Diabetes Prevention Program study sponsored by the National Institutes of Health: Just 30 minutes a day of moderate physical activity combined with a 5 to 7 percent reduction of body weight (7 to 11 lbs. for a 150-lb. woman) produced a 58 percent reduction of diabetes onset among people with pre-diabetes.

Here are answers to frequently asked questions about pre-diabetes.

How is Pre-Diabetes Diagnosed?

Three blood tests may be used to determine borderline high glucose levels. A fasting plasma glucose (FPG) test measures the milligrams of glucose in each deciliter of blood plasma after the person has fasted for at least eight hours. An oral glucose tolerance test (OGTT) measures blood glucose levels up to five times over a period of three hours, and involves a baseline blood count and tests after drinking a glucose solution.

The new “gold standard” is the glycated hemoglobin/A1C test, which measures glucose attached to hemoglobin, a protein found in red blood cells. The non-fasting test uses a single blood sample to get a reading of sugars in the blood over the past two to four months.

As the medical profession’s understanding of diabetes has improved, the benchmark for healthy glucose levels has shifted. Levels that are now labeled pre-diabetic used to be considered good blood sugar levels. “Sadly, what we believed to be good blood sugar control a little over a decade ago led to many patients not being diagnosed early enough and developing the unwanted effects of diabetes,” notes Anderson.

Should I Be Tested for Pre-Diabetes?

Yes, if you are older than 45 and/or you are overweight or obese. If the blood sugar levels are normal, you should be retested every three years.

Because pre-diabetes often occurs in tandem with high blood pressure and abnormal cholesterol levels, you should be tested if you have either of these conditions. The National Diabetes Information Clearinghouse, part of the National Institutes of Health, also suggests that you get tested if you have:

• a parent, brother or sister with diabetes
• a family background that is Alaska Native, American Indian, African American, Hispanic/Latino, Asian American or Pacific Islander
• a history of cardiovascular disease
• other clinical conditions associated with insulin resistance, such as acanthosis nigricans,
• a condition characterized by a dark, velvety rash around the neck or armpits
  polycystic ovary syndrome
• had gestational diabetes or gave birth to a baby weighing more than 9 pounds
• had impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) on a previous test.

Testing is also recommended if you are fairly inactive or exercise fewer than three times a week.

Certified nutritionist Deborah Enos, who practices in Sammamish and speaks around the nation, says that her clients are often resistant to being tested. “People come in with terrible diets,” she says. “When I say, ‘We have to rule out pre-diabetes or diabetes,’ they look at me as though I’m crazy. They feel invincible; they think it can’t happen to them.”

Will I Have Any Symptoms of Pre-Diabetes?

Probably not. Anderson calls it a “silent disease” with “no warning signs early on.” Ann Fittante, a dietitian with Swedish Hospital’s Diabetic Education Center, notes that the symptoms of full-blown diabetes — including unusual thirst, a frequent need to urinate, blurry vision and fatigue — do not show up until blood sugar reaches very high levels. They are rarely evident in people with pre-diabetes.

Davies does not entirely agree. During pre-diabetes, the pancreas keeps making more insulin to keep up with demand. “When you have all this insulin circulating in your blood, it makes you hungrier and so you want to eat even more. You feel sluggish. You want to lie on the couch and do nothing,” he explains. “People actually feel better when they get diabetes (and the pancreas can no longer keep up with insulin demands) because there’s less insulin in circulation.” Enos agrees that being hungry all the time can be a sign of pre-diabetes.

Is Pre-Diabetes Hurting My Body?

Probably. If you have pre-diabetes, “you are starting the clock on wearing out the pancreas,” Davies says. He notes that there have been few longitudinal studies of people with pre-diabetes and so scientists don’t really know how much damage is being done before full-blown diabetes is diagnosed.

“Recent research has shown that some long-term damage to the body, especially the heart and circulatory system, may already be occurring during pre-diabetes,” states the American Diabetes Association (ADA). Research indicates that you have a 50 percent greater risk of cardiovascular disease if you have pre-diabetes — this is far less than the 200 to 400 percent increase for diabetics, but still significant.

“The high (levels of) sugar in the blood and the high insulin cause many inflammatory changes which are silent for years but often lead to the big signs and symptoms of the disease, in most body tissues, as time goes on,” Anderson summarizes.

Is Too Much Sugar the Main Problem?

No. Yes. It depends how you define “sugar.”

Type 2 diabetes used to be called “sugar diabetes” because of the buildup of glucose in the blood, and so we got the idea that too much sugar causes diabetes, Fittante notes. “It’s a major misconception,” she says. She does advise patients to eat desserts in moderation. “But if you are overweight and inactive, weight loss and exercise will do more to prevent diabetes than limiting sugar.” If you had a choice between giving up six candy bars a day or losing 10 pounds, you’d do better to lose the 10 pounds, she says.

“The idea that sugar is the problem is wrong,” Davies agrees. “The concept of too much sugar intake is useless. It doesn’t matter how sweet the food is when you eat it.” He points out that all carbohydrates break down into sugars. Those that break down quickly during digestion and release glucose rapidly into the bloodstream — including cornflakes, Rice Krispies, potatoes, white bread and white rice — are said to have a high glycemic index. If you have pre-diabetes you should limit those types of carbohydrates.

“Sugar is the biggest part of the problem,” says Anderson. “Exercise, reduction of body mass, hydration, proper nutrient intake and other factors are important as well, but sugar drives the disease.” All forms of sugar trigger insulin production, including simple sugars and those derived from carbohydrates, he clarifies.

Should I Go on a No-Carb Diet?

No. Carbohydrates, found in grains, fruits and vegetables provide the body with the fuel it needs for physical activity and proper organ function. It’s the added sugars and over-processed or white grains that cause the problem.

The ADA dietary guidelines for preventing pre-diabetes or slowing its progression to diabetes are the same as the ones for cardiovascular health, ideal weight and cancer prevention:

• Eat lots of vegetables and fruits, in a variety of colors.
• Eat non-starchy vegetables, such as spinach, carrots, broccoli or green beans.
• Choose whole grain foods over processed grain products.
• Include dried beans and lentils in your diet.
• Include fish in your meals two to three times a week.
• Choose lean meats, like cuts of beef and pork that end in "loin," and remove the skin from chicken and turkey.
• Choose nonfat dairy products.
• Choose water and calorie-free "diet" drinks instead of regular soda, fruit punch, sweet tea and other sugar-sweetened drinks.
• Choose liquid oils for cooking instead of solid fats that can be high in saturated and trans fats.
• Cut back on high-calorie snack foods and desserts.
• Watch your portion sizes.

“The food guidelines for pre-diabetes and diabetes are: balanced meals with carbs, proteins and fats at each meal, not leaving out any food groups,” Fittante summarizes.

While saturated and trans fats are problematic, healthy fats (including coldwater fish and nuts with omega-3 fatty acids and mono- and polyunsaturated fats, such as olive and canola oil) should be included with each meal, she says. Desserts should be limited to 200 calories a day, and that figure includes sodas.

Enos, author of the 2007 book Weight a Minute: Transform Your Health in 60 Seconds a Day, adds these suggestions to the general list:

• Eat every two to three hours, taking smaller meals and snacks.
• Try to include a few carbs, some protein, some fiber and some fat in each meal or snack. More fiber can prevent a rapid rise in blood sugar.
• Eat breakfast within 30 minutes of getting up. Do not begin the day with lots of sugar (e.g., pure juices and grains with a high glycemic index), and then starve yourself for hours.

Is Exercise Important?

No one in the field gives any answer but an emphatic Yes!

“Exercise makes your cells more receptive to insulin, so that they receive the glucose and the pancreas doesn’t have to work so hard,” Enos explains. Like other experts, she emphasizes that we do not have to do a lot of exercise to make a difference. She suggests taking a brisk 30-minute walk each day, taking the stairs when possible, and wearing a pedometer — aiming for about 10,000 steps a day. If you want to lose more than 5 or 10 pounds, you will need to increase the intensity or duration of your workouts.

“Activity is a low-insulin state,” Davies concurs. If we’re sedentary, the extra sugar and fat gets stored in the fat cells instead of being used for energy. “You have a 10 to 20 percent chance of progressing (from pre-diabetes) to diabetes each year if you don’t change your choices,” he adds. If they make the changes to improve their diet and exercise more, “people are remarkably successful” in reversing the condition.

Fittante teaches a class on pre-diabetes at Swedish and encourages participants to begin with small changes to gain movement, such as parking farther away and walking. “If you start exercising, you will reduce your risk,” she says. “Diet and exercise work.”

Success Stories

North Seattle resident Carol Jahn can attest to that. She was diagnosed with pre-diabetes five years ago. She had no symptoms, but her doctor suggested having her blood sugar tested because she was struggling with weight gain. In her case, the pancreas was not producing enough insulin, and she began having to take it by injection. She also took metformin, an oral anti-diabetes drug that helps control blood sugar levels.

After a year on insulin, she went to the Black Hills Health and Wellness Center in South Dakota for three weeks to learn lifestyle changes she could take home with her. The diet was vegetarian and as close to nature as possible with no processed foods and lots of grains, legumes and vegetables and some fruit. The group stretched in the morning, walked or rode an exercise bike before breakfast, walked in the afternoon and evening, and did weights with a personal trainer.

“It was well worth the cost to get off insulin and other medications,” Jahn says. She continues to see a naturopath and says she is still considered a diabetic — although her A1C reading is in the normal range. “I am using diet and exercise, not drugs at this point,” she adds.

Anderson has a strong family history of type 2 diabetes, and was diagnosed with the disease a few years ago. “I was getting to the point that I needed metformin,” he says. After he lost 40 pounds with diet and exercise, he was able to avoid the drugs and did not have to begin taking insulin. “I try to do something active four to six days a week, for about an hour,” he says. “I try to work it into my routine. Most of my carbs are from raw or lightly steamed vegetables that are low in starch. I don’t worry about going off my diet on my birthday or celebration days.”

“The more people do with their level of exercise and diet, the fewer drugs they’ll need,” Anderson says. “The patient has a lot of control.”

Wenda Reed is a Seattle-area health writer with a blood sugar level not quite in the pre-diabetic range, but high enough to make her more vigilant about walking 30 minutes a day and eating even fewer high-sugar, high-calorie garbage foods.

TYPES OF DIABETES

TYPE 1 DIABETES is usually diagnosed in childhood or young adulthood and is also called juvenile diabetes. It is an autoimmune disease in which antibodies in the bloodstream attack and kill the cells in the pancreas that make insulin. It is not caused by being overweight or obese or by eating too much sugar or starch. People must inject themselves with insulin every day of their lives.

TYPE 2 DIABETES, the most common kind, was traditionally diagnosed in adulthood, but now more children are getting it. There is a strong genetic component, but being overweight and sedentary greatly increases the risk. In type 2 diabetes, either the body does not produce enough insulin or the cells do not use it properly. If the disease cannot be controlled through exercise and diet, the patient will have to use insulin injections.

PRE-DIABETES AND DIABETES RESOURCES

Weight a Minute! Transform Your Health in 60 Seconds a Day, by Deborah Enos, CN: Short, easy-to-read diet tips for all aspects of health, including preventing diabetes and the high cost of being overweight. www.deborahenos.com.

The Sugar Solution, The Sugar Solution Cookbook and the Diabetes Diet Cookbook by Ann Fittante and the editors of Prevention magazine: Explains how high blood sugar from pure sugars and carbohydrates affects your system; hundreds of recipes.

American Diabetes Association: www.diabetes.org. Take a quick risk assessment at www.diabetes.org/diabetes-basics/prevention/diabetes-risk-test to see if you should be tested for pre-diabetes or diabetes.

The Joslin Diabetes Center, affiliated with Harvard Medical School: www.joslin.org/info/what_is_pre_diabetes.html.

Centers for Disease Control and Prevention: Frequently Asked Questions about pre-diabetes. www.cdc.gov/diabetes/faq/prediabetes.htm.

Small Steps. Big Rewards. Prevent Type 2 Diabetes Campaign: Prevention materials and fact sheets prepared by the National Diabetes Education Program, a partnership of the National Institutes of Health, the Centers for Disease Control and Prevention and 200 other organizations. www.ndep.nih.gov/partners-community-organization/campaigns/SmallStepsBigRewards/aspx.

Local Classes

Swedish Diabetes Education Center, Seattle: Two-hour class on pre-diabetes taught by a registered dietitian, twice monthly. 206-215-2440. www.swedish.org.

Evergreen Healthcare, Kirkland: “Diagnosis: Pre-Diabetes” class offered periodically; next class, June 3, 6:30-8:30 p.m. 425-899-3000. 12-week Diabetes Prevention Program for people at risk, including education and exercise; classes begin when enough people sign up. 425-899-3001. www.evergreenhospital.org/classes.

All local hospitals and medical centers offer classes, support groups and dietary guidance for people diagnosed with diabetes; most of these are open to people with pre-diabetes or those at risk for developing it.

©Copyright 2010, Caliope Publishing Company