Pondering the Intensity of Preventing Type 2 diabetes

There’s something that’s always puzzled me: If, as so many say, Type 2 diabetes stems from too much weight, then how come the Centers for Disease Control and Prevention (CDC) says there are 97 million overweight and obese people in the United States, but only 14.6 million people diagnosed with diabetes? Even after subtracting the people with Type 1 diabetes, where are the other 80 million or so people with Type 2 diabetes? Have they not been diagnosed yet?

Or could it be that they just don’t have the right genes?

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I have my own opinions about Type 2 diabetes. One is that the genetic part is very strong. I’m even more convinced after rereading the results of the Diabetes Prevention Program (DPP), which were published in the February 7, 2002, edition of The New England Journal of Medicine (NEJM).

You may recall the program, in which people with impaired glucose tolerance, or prediabetes, were divided into groups, including an intensive lifestyle modification group. You may also recall the elation of the health-care world when it was learned that intensive lifestyle changes eliminated or delayed the onset of Type 2 diabetes when compared to standard lifestyle recommendations plus metformin and standard lifestyle recommendations plus placebo.

Since then, it seems that many people think all we have to do is change our evil ways and we’ll never get Type 2 diabetes.

Please keep in mind that I’m neither a health-care professional nor a researcher. But a couple of things struck me when I took a closer look at the results of the DPP:

  • The people in the intensive lifestyle modification group got a lot more help than those in the other groups; and
  • Many people in the intensive lifestyle modification group developed Type 2 diabetes anyway.

What did the people in the intensive lifestyle modification group get? “A 16-lesson curriculum covering diet, exercise, and behavior modification…designed to help the participants achieve” the goals of losing 7% of body weight through a healthy low-calorie, low-fat diet and engaging in at least 150 minutes of exercise per week, according to the NEJM article.

“The curriculum, taught by case managers on a one-to-one basis during the first 24 weeks after enrollment, was flexible, culturally sensitive, and individualized. Subsequent individual sessions (usually monthly) and group sessions with the case managers were designed to reinforce the behavioral changes.”

And the other groups? They got some written information and an “annual 20- to 30-minute individual session that emphasized the importance of a healthy lifestyle.” They were also encouraged to increase their exercise and follow the food pyramid guidelines and the equivalent of the National Cholesterol Education Program Step I diet.

I won’t even try to figure out how many of us had the advantage of a 16-lesson curriculum, etc., but I’d guess…oh…nada. Zip. Zilch.

Heck, many of us don’t even get a booklet, a pat on the back, and 20 to 30 minutes of education that emphasizes a healthy lifestyle. Even basic diabetes education is inadequately funded, much less intensive education. If “they” are really serious about reducing the incidence of Type 2 diabetes, then they need to bring on the needed support.

But don’t think that all the hand-holding and education in the world will eradicate Type 2. In the intensive lifestyle cohort, there were 1,079 people, the average length of the trial was 2.8 years, and, during that time, there were 4.8 cases of Type 2 diabetes per 100 person-years. If you crunch the numbers, it turns out that nearly 145 of the people in the intensive lifestyle modification group got Type 2 diabetes despite the individual assistance and encouragement.

Granted, intensive lifestyle intervention reduced the incidence of Type 2 diabetes by 58% when compared to the placebo group and by 31% when compared to the metformin group. But, while less is better, Type 2 wasn’t totally eliminated.

Remember, too, that the average length of the trial was less than three years. It makes me wonder how many more people in that group have gotten Type 2 in the six years since.

  • Priscilla

    Great article…covered things I’ve been wondering about.

    I would like more education than I am getting. I feel like I have to find out everything on my own and sometimes I get conflicting information which is really frustrating.

  • Paul

    Thoughtful, inquizative, helpful. Thank you for asking some important questions. If you hear answers let us know. TThanks

  • Ann

    Well said, Jan!

    Here is a fact supporting your ideas, one that many people find surprising: Identical twin studies show a much stronger genetic predisposition for type 2 diabetes than type 1. If one identical twin has diabetes, there is a less than 50% chance that the other twin will too. However, if one identical twin has type 2 diabetes, there is a close to 100% chance that the other one will too.

    Clearly, there is a genetic predisposition for both type 1 and type 2. But the genetic predisposition is much stronger for type 2.

    My own theory is that if you have the genes for type 2 you will develop it eventually if you live long enough. It would be a good thing to keep your weight in control, exercise vigorously all your life, and eat low-glycemic-index foods almost all of the time. Then you might not develop type 2 diabetes until you are 140 years old, by which time you would have died of something else. I know some people who seem to be doing this. Good luck to them!

  • lsullivan

    I quite agree with the opinion of the author.

    I have never been overweight, smoked, or drank excessively. I have always eaten well-balanced meals and exercised regularly. In other words, I have led a healthy life style. Yet at the age of 47 I was diagnosed with Type 2 diabetes.

  • natasha

    Hi All: I was wondering about the DDP study; was it done in 2002? Was this a vegan diet group?

  • roslyn

    Hi,
    This is my first time using your blog page. I liked Jan Chait’s article & agree with a lot she said. I was first diagnosed with type 2 diabetes a year ago this month. I was told that many who are diagnosed probably had it for some time before diagnosis. I believe that is the case with me as I was without insurance for 1 year and before that my doctor never checked me for diabetes. I could not lose weight no matter what I did but since diagnosis I have lost 15 lb. by cutting way back on sugar. My doctor calls me his star patient. My numbers are really good,A1c is under 7. I would like to add that if someone needs to get insurance try looking into Kaiser. The day I turned 65 I was eligible for Kaiser(before I was too high risk for them)Right away I was given a full physical and that is how I diagnosed with my diabetes. Kaiser is a great place as they educate their patients well. I was sent to a 3 mo. class (1 class/month for 2-3 hr.)I learned more than I ever could have read.

  • Jan Chait

    Natasha, initial results of the DPP were published in February 2002 in the New England Journal of Medicine. The study itself took place before that. I did not read anything that indicated it was a vegan diet group.

  • Gruntwilligar T. Honkenoffski

    I wonder how many antarctic explorers might get diabetes? For instance, if a scientist is studying a colony of Penguins and exposed to the frigid conditions of Antarctica, would that scientist have a greater or lesser chance of developing the disease?

    Gruntie

  • Grace

    Thanks for this info. I have always taken really good care of myself and gets lots of exercise, but appear to be developing diabetes and high blood pressure. It seems like all my efforts counted for nothing.