Disease Risk From Diabetes Cut With Intense Therapy

Treatment Addresses Heart And Kidney

Diabetes researchers have found more evidence that aggressive treatment can prevent - and sometimes reverse - the ravages of the disease, according to a report in the New England Journal of Medicine.

Of the two new studies reported, one adds to previous research and the other upends prior assumptions. Both of the new studies look specifically at type 1 diabetes. An accompanying editorial points out results of type 1 diabetes trials can, with certain limitations, be extended to type 2 diabetes.

Some 17 million people in the US suffer from diabetes. Most of these people have type 2 diabetes, in which the body's ability to produce insulin is hampered but not completely destroyed.

In the case of type 1 diabetes, which comprises about 10 percent of all cases, the body's immune system attacks the insulin-producing cells so the body cannot produce the essential hormone at all. Either type of diabetes can cause blindness, kidney failure, amputations, heart disease, and stroke.

About a decade ago, the landmark Diabetes Control and Complications Trial (DCCT) found people with type 1 diabetes who tightly controlled their blood glucose levels reduced the risk of eye, nerve, and kidney complications by 35 percent to 76 percent.

The study participants were too young, however, to assess the affect on atherosclerosis, or hardening of the arteries due to plaque buildup.

Preventing Heart Disease

The new study, the Epidemiology of Diabetes Interventions and Complications (EDIC) study, presents the good news that intensive diabetes management can also reduce the risk of atherosclerosis in people with type 1 diabetes.

The EDIC trial involved 1,229 patients with type 1 diabetes who had also been in the earlier DCCT trial. They were divided into two groups: 611 who received conventional treatment and 618 who received intensive management.

The researchers used ultrasound to measure the thickness of the wall of the participant's carotid arteries at the beginning of the trial and after five years. The carotid arteries, located in the neck, carry blood from the heart to the brain.

"We're measuring the innermost layer and then the next layer in," explains study author Dr. David M. Nathan, director of the Diabetes Center at Massachusetts General Hospital. "Those are the layers that are characteristically affected by atherosclerosis, and it presages the development of vascular disease."

After five years, the thickness was significantly less in the diabetics who had followed an aggressive glucose-management campaign during the earlier trial.

"The group that was treated intensively had a slower rate of progression," says Dr. Nathan.  "It appears that the advantage of therapy aimed at keeping blood glucose levels as close to the nondiabetic range as possible benefits not only diabetes-specific complications, but also cardiovascular diseases."

Dr. Nathan was quick to add that, so far, the regimen did not decrease heart attacks or strokes.

But, the atherosclerosis measurement is "a well-recognized surrogate marker" of disease, and "we were able to make a difference. . . You need to apply this therapy as early as possible, and continue to apply it."

Preventing Kidney Disease

The second study looked at microalbuminuria, or the presence of protein in the urine, which is the earliest sign of kidney disease.

Until now, conventional wisdom held that kidney disease was inevitable in people who had microalbuminuria. The best you could do was slow the progression of a disease that would eventually lead, in one-third of patients, to end-stage renal disease and dialysis or a transplant.

This study has found that diabetics can do better than just slow down the disease.

"In the early stages, it looks like the disease process can be reversed if patients do the optimal things," says study author Dr. Bruce Perkins, a fellow in endocrinology at the Joslin Diabetes Center in Boston.

"The important finding was that it does look like there is a mechanism where the kidney can heal itself and, in fact, it seems to do it quite often," Dr. Perkins says.

The researchers looked at 386 patients with type 1 diabetes and with microalbuminuria that had been present for two years. The subjects were followed for an additional six years. At the end of that time, 58 percent of the participants no longer had any protein leakage.

"People who do reverse tend to have the lowest blood sugars, lowest blood pressure and, most importantly, the lowest cholesterol levels," Dr. Perkins says. "It seems likely that aggressive treatment is necessary to reverse microalbuminuria."

The first message, then, is that screening is critical.

"Someone with diabetes shouldn't allow years to go by without being screened for microalbuminuria because if it's identified early, if we do the right things, it can be reversed," Dr. Perkins says.

Physicians and patients alike should perhaps also pay more attention to cholesterol levels, including the possibility of taking cholesterol-lowering drugs, although this should first be studied in a clinical trial, Dr. Perkins says.

In the longer term, the findings may help identify targets for new medications. A priority is to figure out how the kidney manages to repair itself even after early initial damage, Dr. Perkins says. He and his colleagues believe a different part of the kidney's filtering structure, the tubules, may be more central than originally thought.

"This is a fundamentally important thing because it changes the way we think about understanding kidney disease and also finding treatments for it," Dr. Perkins says.

Always consult your physician for more information.

Online Resources

American Diabetes Association

Centers for Disease Control and Prevention (CDC)

HealthierUS.Gov

National Diabetes Education Program

National Diabetes Information Clearinghouse

National Institute of Diabetes & Digestive & Kidney Diseases

National Institutes of Health (NIH)

National Library of Medicine

Prevengamos la diabetes tipo 2. Paso a Paso

August 2004

Disease Risk From Diabetes Cut With Intense Therapy

Preventing Heart Disease

Preventing Kidney Disease

Pre-Diabetes a Risk for Hispanics

Online Resources

Other Resources:

Find a St. John's Mercy Physician

Diabetes Services at St. John's Mercy

Diabetes Health Information

St. John's Mercy Classes and Programs

Pre-Diabetes a Risk for Hispanics

About 40 percent of US adults ages 40 to 74 - millions of whom are Hispanic or Latino - currently have pre-diabetes, a condition that raises a person's risk of developing type 2 diabetes, heart disease, and stroke.

To respond to this rapidly growing problem, experts from the US Department of Health and Human Services' National Diabetes Education Program (NDEP) and community-based organizations from around the country met recently at the National Council of La Raza's (NCLR) annual conference to discuss national and local efforts to stem the diabetes epidemic in the Hispanic community.

"Every minute of every day, another American develops type 2 diabetes," said Dr. Saul Malozowski, senior advisor for Clinical Trials and Diabetes Translation at the National Institute of Diabetes and Digestive and Kidney Diseases.

"Without intervention, one in three children born in the year 2000 will develop diabetes in his or her lifetime," Dr. Malozowski says.

"For some of us, the risk is even higher. If that child is Hispanic and female, she has a one in two chance of developing diabetes in her lifetime. We need to get the word out that type 2 diabetes prevention is proven, possible, and powerful," he says.

While diabetes is a growing epidemic for Hispanics, a recent landmark study found that type 2 diabetes can be delayed or prevented in people at risk for the disease.

The National Diabetes Education Program (NDEP), a joint effort of the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC), developed a bilingual diabetes prevention campaign in response to the results of the Diabetes Prevention Program (DPP) clinical trial: "Prevengamos la diabetes tipo 2. Paso a Paso" (Let's Prevent Type 2 Diabetes: Step by Step).

The campaign highlights the study's findings that by losing a small amount of weight, limiting fat and caloric intake, and exercising 30 minutes a day, five days a week, participants dramatically reduced their risk for diabetes by more than half. More than 500 Hispanics participated in the DPP.

"With 'Paso a Paso,' we are asking Hispanics to find out if they are at risk for diabetes, and we're showing them how to take action to prevent it," said Yanira Cruz, the chair of the NDEP Hispanic/Latino Work Group.

"The key is modest weight loss and regular physical activity," she says. "I want to encourage people to take this message of good health to their families and their communities, so we can put an end to the diabetes epidemic."

José Cortez took this message to his family and community after learning about the success of diabetes prevention efforts by other Latinos.

Cortez, who works for Chicanos Por La Causa, a statewide community development corporation in Phoenix, now hikes regularly with his family, and even coordinates an annual hike for his organization.

Cortez shared his successes - both personally and professionally - to spread the message of diabetes prevention.

"Chicanos Por La Causa creates opportunities for leaders in the community," says Cortez. "But strong leaders need to be healthy. For me, that means hiking regularly, but for others that may mean taking a walk during lunch or substituting fruits and vegetables for less healthy foods. But taking the first step is always the most important."

To help Hispanics take their first step, the NDEP is offering a new music CD free of charge to help Hispanics get more physical activity to prevent type 2 diabetes.

Performed by a diverse group of Hispanic recording artists, MOVIMIENTO, Por Su Vida (Movement, For Your Life) is a collection of six original songs with a Latin dance beat and lyrics that celebrate life in an effort to promote physical activity as a way to stay healthy and help prevent diabetes.

"Everything counts - taking the stairs, walking the dog, dancing to music, mowing the lawn - small changes can be easily incorporated," said Cruz. "Physical activity just needs to occur every day. Make it fun and take it step by step!"

Always consult your physician for more information.