Nutrition

Genes

We have an explosion of type 2 diabetes in the US primarily due to unhealthy lifestyles. Poor eating habits, being overweight or weight gain over time, and lack of exercise can increase your risk for type 2 diabetes. Type 2 diabetes usually occurs in persons over 40 years of age and who are overweight, have a family history of diabetes, or are African-American, Hispanic, Asian Pacific Islander, or American Indian. Type 2 diabetes is controlled by diet, but oral medication or insulin may be needed later. Type 1 diabetes usually occurs at a younger age, is caused by an auto-immune disorder, and always requires insulin injections or the insulin pump. Most persons with diabetes have type 2 diabetes (about 90% of all cases of diabetes). Gestational diabetes is also a risk factor for type 2 diabetes later in life. Again, a healthy lifestyle can reduce this risk for both gestational diabetes and type 2 diabetes.

It has been estimated that 16 million persons in the US have diabetes, and of these, over 5 million are presently undiagnosed. As reported in the Journal of the American Medical Association(1), the prevalence of diabetes has increased from 4.9% in 1990 to over 7% in 2000, primarily due to the tremendous increase in obesity in the US. This report shows that even though all 50 states have a growing problem of obesity, Mississippi leads with an obesity rate of 24.3% of its residences compared to Colorado with the lowest rate of 13.8%. As one would expect, Mississippi also leads the US with the highest rate of diabetes, 8.8%, compared to Alaska with the lowest rate, 4.4%. This describes the "perfect storm", overweight breeds diabetes, and indeed as reported in the Diabetes Interview(2), 80% of persons with type 2 diabetes are overweight. These findings have led our experts to develop a new term, "diabesity".

An explosion of type 2 diabetes has occurred in persons under age 40, in particular, persons in their 30s and children and teens. It has been reported in Diabetes Self-Management(3) that during the1990s, the incidence of diabetes increased by 76% in persons aged 30-39 years. This same publication(4) reports that in those children and teens who have diabetes, the incidence of type 2 diabetes has increased from 2-4% to 15-20%. This is especially disturbing because we know that 20 years of diabetes results in complications, costly both in quality of life and health care dollars. By the time these individuals are 40 years of age, they can experience costly life-threatening complications. There are studies, however, that show type 2 diabetes can be prevented.

The Diabetes Prevention Program (DPP), sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases and other national organizations, is a randomized clinical trial of diabetes prevention in more than 3,000 overweight men and women aged 25-85 years with impaired glucose tolerance. Forty-five percent of the participants represent ethnic groups having a high incidence of type 2 diabetes. An American Diabetes Association publication(5) reports that in this study, those patients in the exercise/low fat diet group who reduced their weight by 7% and exercised moderately for 150 minutes a week, reduced their chances of developing type 2 diabetes by 58%. This finding was consistent for men, women, all ages, and all ethnic groups. This study shows that you CAN prevent type 2 diabetes with a healthy lifestyle of exercise and a low fat diet that results in some weight loss.

An even more dramatic finding that a healthy lifestyle can prevent type 2 diabetes is documented in the September 13, 2001 issue of The New England Journal of Medicine(6). This randomized clinical trial of more than 85,000 nurses, age 30-55 years at enrollment and followed for 16 years, showed that 91% of newly diagnosed type 2 diabetes could be prevented in persons who weighed less, ate healthfully, exercised, avoided smoking, and drank alcohol minimally. In this study, it appears that family history of diabetes, socioeconomic status, or ethnicity does not affect the risk for type 2 diabetes.

The nurses in the unhealthy lifestyle or study group had no diabetes, cardiovascular disease, or cancer, and information about their lifestyles was periodically updated. A low risk comparison group representing more healthy lifestyles was selected based on having a normal weight, eating healthfully, exercising, not currently smoking, and consuming 1/2 an alcoholic drink a day.

A normal weight is defined as having a Body Mass Index (BMI) less than 25 (eg weighing less than 150 lb at 5'5" or less than 184 lb at 6').

Eating healthfully is defined as (1) eating a diet high in cereal fiber (interpreted as 2-3 grams of fiber per Â½ c serving of cooked cereal or 1 sl bread) including whole grain breads and cereals, bran, bulgur, kasha, couscous, oats, brown rice, and wheat germ; (2) eating a diet high in polyunsaturated fats such as corn, safflower, sunflower, soybean, cottonseed, and sesame oils and walnuts and pumpkin seeds;
(3) eating a diet low in trans-fat (the partial hydrogenation of vegetable oils found in cookies, dessert foods, snack chips, crackers, and stick margarines) having less than 0.5 g trans-fat and 1 g saturated fat per serving of food; and (4) eating a diet low in glycemic load. The glycemic index is a ranking of foods containing carbohydrate with the potential to raise blood glucose. Form and content of a food can affect its glycemic index. Various foods having a high glycemic index include white bread, cold cereal, white rice, potato, French fries, and sugar. Various foods having a low glycemic index include pumpernickel bread, oat bran bread, All-Bran, parboiled rice, sweet potato, lentils/kidney/baked beans, apple/banana/plum, stone wheat thin crackers, and skim milk. The glycemic load is mathematically determined by how much carbohydrate food having a high glycemic index is consumed in a day.

Carbohydrates include starchy foods such as potatoes, corn, peas, pasta, rice, breads, cereals, crackers, and popcorn; fruits; milk; and sweets. Usually 1-2 servings of starch, a serving of fruit, and a serving of milk are plenty carbohydrate for one meal. Overeating carbohydrates or carbs is quite common, especially for people on the go. Eating more of these foods than is needed can of course contribute to weight gain as can overeating any food. It is especially recommended to select and eat carbohydrate foods having a high fiber content such as whole grain breads/cereals, dried beans/peas, vegetables, and fruits, while limiting highly processed and instant foods, snack foods, and sweetened foods. Double jeopardy occurs, as reported in this NEJM article, when weight gain is accompanied by a diet including carbohydrates with a high glycemic index or load. It has been proposed that eating carbohydrate foods with a high glycemic load can increase the need for insulin, possibly causing insulin resistance and subsequent type 2 diabetes. Consuming an overall healthy diet reduces the risks for not only diabetes but heart disease and cancer as well. In addition to the carbohydrate food intake servings recommended above, eat limited amounts of animal protein such as meat, fish, poultry (about 6 oz daily); limited fat and rich foods; and plenty of vegetables such as tomatoes, broccoli, cabbage, squash, and spinach. Some persons may need different amounts, for example pregnant females.

Exercising moderately-to-vigorously (brisk walking, jogging, heavy gardening, heavy housework, or other activities that cause you to sweat) for at least a Â½ hr daily can reduce a person's risk for type 2 diabetes. Consult with your physician.

Not currently smoking reduces a person's risk for type 2 diabetes.

Consuming ½ an alcoholic drink a day reduces a person's risk for diabetes. Please use caution/consult with your physician.

This NEJM article documented that even having a weight in the higher range of normal nearly tripled the risk for diabetes. This would indicate trying to at least maintain your weight through the years and avoiding even a 1-2 lb gain per year. Women who exercised 1 hr daily reduced their risks for diabetes in half compared to women who exercised less than Â½ hr a week. The authors close with the prediction that since risk factors in the general population are more prevalent than in this group of nurses, the effect of lifestyle change will be much greater in the general population in reducing the risk for type 2 diabetes.

The above information shows dramatically how your health lifestyle can affect YOUR risk for type 2 diabetes. And what is recommended is not really that hard to do. We put similar amounts of energy into projects and activities that may not be nearly as important in the long run. Think about it! You can do it!

REFERENCES

(1) Mokdad, A. H., Bowman, B.A., Ford, E. S., et al. (2001). The Continuing Epidemics of Obesity and Diabetes in the United States. Journal of the American Medical Association, 286, 1195-1200.

(2) Spiegel, A. (April 2001). Understanding Type 2 Diabetes. Diabetes Interview, 24.

(3) Gustaitis, J. (Nov/Dec 2001). New Diabetes Guidelines. Diabetes Self-Management, 40.

(4) Ternand, C. L. (Sept/Oct 2001). Type 2 Diabetes in Children and Teens. Diabetes Self-Management, 75-77.

(5) American Diabetes Association. (Fall 2001). Diabetes Prevention Proven. Professional Section Quarterly, 1.

(6) Hu, F. B., Manson, J. E., Stampfer, M. J., Colditz, G., Liu, S., Solomon, C. G., & Willett, W. C. (Sep 13, 2001). Diet, Lifestyle, and the Risk of Type 2 Diabetes Mellitus In Women. The New England Journal of Medicine, 345(11), 790-797.