July 29, 2014
   
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The Fight Against Diabetes
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The Fight Against Diabetes

 
Dr. Zonszein is Professor of Clinical Medicine, Albert Einstein College of Medicine. All authors are staff members of the Clinical Diabetes Center of Montefiore Medical Center, New York.


Diabetes is not just one disease; it is really several different diseases. What most people mean when they talk about diabetes is either Type 1 or Type 2. The simplest way to distinguish between them is that people with Type 1 need insulin at all times for survival, as their body makes no insulin, while people with Type 2 can be treated with oral medications and or insulin. A healthy diet and adequate exercise are also important components in treating diabetes.

Type 2 diabetes is growing at alarming rates due to the changes in our population.

Insulin is a natural substance that is used by the body to transform sugar and other nutrients into energy. A lack of insulin or an inability to respond to insulin — so-called "insulin resistance" — causes hyperglycemia, or high levels of sugar in the blood. This in turn causes damage in small and large vessels resulting in heart attacks and strokes, in internal organs including the liver causing hepatitis, in the eyes causing blindness, in the kidneys causing kidney failure and need for dialysis, etc.

Type 2 diabetes is growing at alarming rates due to the changes in our population — racial/ethnic minorities are more susceptible to develop obesity and Type 2 diabetes. In the Bronx, one of the five boroughs of New York City, for example, where there is an expanding population of ethnic minorities who are susceptible to Type 2 diabetes, an astounding 18% of the total population has diabetes. (www.nyc.gov/html/doh/downloads/pdf/email/dohmhnews5-04.pdf). Most frighteningly, the disease is afflicting a younger population and causing more and more premature disability and death. To help fight diabetes, the New York City Board of Health recently mandated electronic reporting of Hemoglobin A1c (HbA1c), a test that measures average blood sugar levels, in order to keep track of this growing epidemic and to identify populations that are particularly affected.(1)

HbA1C (also known as hemoglobin A1c, A1C, glycohemoglobin, glycated hemoglobin and glycosylated hemoglobin A1C) measures the average blood sugar level and is a good predictor of diabetic complications.(2)(3)(4)(5)(6)(7) The reason for this is that blood sugar levels can vary wildly from day to day or even from hour to hour. The A1C test, on the other hand, measures average blood glucose levels over the 120-day life span of a red blood cell, and is particularly accurate for the 8 to 12 weeks preceding the test. This is extremely important because research has shown that the more tightly a person's blood sugar levels can be controlled, the less damage the disease will do to the body.

The American Diabetes Association recommends obtaining HbA1c at least twice a year for diabetics under good control (less than 7%) and quarterly in people whose treatment has changed or whose goals (more than 7%) are not being met.(8) Though blood sugar targets should be tailored to the individual — balancing life expectancy and existing complications against the risk of hypoglycemia (low blood sugar) — the recommended target value for HbA1c is under 7% or as close to that as possible without causing significant hypoglycemia. Today, this goal remains largely unmet, with only 37% of American adults with diabetes having values below 7%.(9)

Type 1 or Type 2?
As stated above, diabetes is really a group of diseases in which defects in insulin secretion, insulin action or both cause high blood sugar.(10)(11)(13)Sometimes these defects are caused by an "autoimmune reaction" in which the body attacks the part of the pancreas that produces insulin resulting in Type 1 diabetes.(12) The vast majority of diabetes cases have Type 2 diabetes caused by resistance to insulin and the inability of the pancreas to produce sufficient amounts of insulin.

Most of the time, it is fairly easy to tell Type 1 diabetes from Type 2, as illustrated by Table 1.

Table 1.
Characteristics of T1DM vs. T2DM.

T1DM T2DM
Age Younger <18 years old Older >40 years old
Race Common in Caucasians Common in ethnic minorities
Family history No Yes
Genetic susceptibility through major histocompatibility complex (MHC) and HLA alleles Yes No
Islet cell antibodies Yes No
Insulin production Deficient Present
Associated autoimmune disorders Common Rare
Onset Abrupt Insidious
Ketoacidosis Common Rare
Central obesity Rare Common
Dyslipidemia (increased triglycerides and low HDL-cholesterol Rare Common

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