Pondering the Intensity of Preventing Type 2 diabetes

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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?

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.

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