When discussing diabetes with non-medical professionals, it often strikes me how many people have misconceptions about disease, its onset and its symptoms and treatments. Last May, I was honored (and got to Kiss a Pig!) at the annual American Diabetes Association fund raising gala. The purpose of the contest, in addition to raising funds for the ADA's mission, is to raise awareness of diabetes and pre-diabetes, otherwise known as insulin resistance. Diabetes is defined by elevated blood glucose, commonly called blood “sugar.” Type 1 (10% of diabetes) is caused by a deficiency of insulin production due to destruction of the cells in the pancreas that produce insulin. It usually starts in childhood, and requires supplemental insulin from the very beginning to survive.
90% of diabetics are Type 2. They produce plenty of insulin, but their bodies don’t respond as well as non-diabetics. It typically begins later in life, starting predominantly in adulthood (although children are being diagnosed at alarming rates), is influenced by genetics and is highly associated with obesity, especially when the fat is centered around the waist. We call this “central” or“apple shaped” obesity.
Diagnosis is based on either a fasting blood glucose that exceeds a certain level or a blood glucose that rises higher than a certain level in response to a standard load of glucose (glucose tolerance test). Other tests may be simpler to administer, but the 2 hour glucose tolerance test is the most informative.
While some have been screened using Hemoglobin A1c, this test is used most appropriately to monitor the control of known diabetics. It misses too many cases and sometimes misidentifies some as diabetic when they are not.
By the time one meets the criteria for diabetes, there have been years or even decades of insulin resistance. Think of driving your car, pressing on the accelerator to go faster. If you rest your other foot on the brake, it will take more gas to achieve the same speed and ultimately damage your car.
Being insulin resistant requires the pancreas to produce more insulin to maintain glucose levels in a healthy range and allow glucose to enter cells to produce energy. Glucose rises when the pancreas can no longer overcome the resistance as insulin production drops. Think of the car slowing down with the accelerator pressed to the floor because the brake pressure can’t be overcome. The car slows under the strain.
This state of resistance (which can go on for years) is not a time for complacency. The blood sugar may be normal when measured, but damage is being done. Atherosclerosis (hardening of the arteries) is accelerated in this state. Often the first sign of a serious problem is a heart attack or stroke. That doesn’t need to be the case.
If you are a male with a waist line of more than 40 inches or a female greater than 35 (measure around your belly button, not where you wear your belt!), if you have high blood pressure, high triglycrerides, low HDL or fasting glucose greater than 100 you should have a glucose tolerance test. Our threshold for diagnosing diabetes is too high to identify those who are insulin resistant. If your 1 hour glucose is greater than 125 or the 2 hour greater than 120, you are likely to be insulin resistant, at high risk of going on to become diabetic and your arteries are at risk. Consider being tested if you have relatives with Type 2 Diabetes.
The reason we should act earlier in the course of insulin resistance is that weight reduction (by lowering intake of sugar) and exercise (more intensely than most of us think necessary) can delay or completely avoid the need for medications. More importantly, it can prevent the silent progression of atherosclerosis.
Bottom line: Don’t wait till you are clearly diabetic. If your doctor won't take action until you meet the criteria for “diabetes”, find someone who will help you pro-actively control your health. Don’t let a fatal or life-altering event be the first sign. I would be happy to offer consultation without long term obligation.