"THE HEART OF THE MATTER"
a special program of the National Emergency Medicine Association (NEMA)


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Week: 598.7 

Guest: Dr. James R. Gavin III, Sr. Science Officer, Howard Hughes Medical Inst. 

Topic: New diabetes guidelines 

Host/Producer: Steve Girard 

NEMA: Our biggest killers....the diseases that wear us down, and take years or decades off our lives...are often preventable. Heart disease and stroke, lung cancer...we know how to prevent them from taking us. Eat healthy, exercise more, don't smoke. Same goes for diabetes, which can rob us of our sight, our kidneys, our limbs...in many cases, very preventable. There are millions of us walking around with diabetes who don't know it. With this in mind, an international panel of experts has rewritten the guidelines by which the medical community diagnoses and classifies diabetes, and here to talk about it today is Dr. James R. Gavin, Senior Science Officer of the Howard Hughes Medical Institute near Washington, D.C., who chaired the panel. Dr. Gavin, let's start by defining the disease.... 

GAVIN: Diabetes is a disease in which the body either does not produce an adequate amount of, or does not respond to the hormone, insulin. And that's what gives us two types of diabetes. The type in which the body can no longer make insulin is called Type 1 diabetes, and That's usually because the body's immune system simply destroys cells that make insulin. These people require insulin for life...or else they become very ill, and may die. that's only about 5% of diabetes in this country. The remainder consists of what we call Type 2Õ diabetes...That's the vast majority of people, usually older people in their 40Õs or more. This is the type of diabetes where people can still make insulin, but their body simply doesn't respond normally to the hormone. And over a period of time, they can lose the ability to make insulin. And so these are people who have to be treated in different ways, depending on where they are in the course of the disease. So, type 2 diabetes is a very different kind of disease from type 1. In either case, the hallmark of diabetes is high blood sugar...that's common to all forms of diabetes...and its the high blood sugar that cause the problems: the eye disease, the blindness, the kidney failure, the strokes, the heart attacks and the amputations. So, all forms of diabetes are serious, and have to be treated aggressively. 

NEMA: Now the numbers...how many people have been diagnosed with disease, and there's an estimate out there on how many people have it...but don't know it....? 

GAVIN: In this country, we have about 16 million people who are affected by diabetes. Now, roughly one million of those have that type 1 form of diabetes that we talked about. The rest are primarily the type 2. In those people who have type 2 diabetes, only about half of those cases have been diagnosed....the other half are walking around right now, with the disease, but they don't know they have it. These are the undiagnosed, and these people we worry about...a lot.  

NEMA: How has our take on diabetes changed since the last time official guidelines came out...nearly 20 years ago? 

GAVIN: In 1979, when we had the first set of guidelines for the diagnosis and classification of diabetes, we didn't know what the immune processes were that led to the destruction of the insulin-producing beta cells in the pancreas. We now know what those processes are. And we also know a great deal more about some of the genetic abnormalities, some of the gene mutations, that lead to various forms of diabetes. And so it's this better understanding of what the underlying causes are, that now allows us to put different types of diabetes into very specific niches, and each niche means that you might have to take a slightly different approach to it. And that's very important when you want to make sensible decisions about how to best treat somebody... and that's a very fundamental change since 1979. 

NEMA: let's talk about the newly created guidelines which have been endorsed by the NIH...the part that's made the biggest news so far is the age to begin regular testing for diabetes.... 

GAVIN: One of the recommendations that we made stems from survey data and research that shows there is a very sharp rise in the prevalence of diabetes after a certain age cut. And that age is around 40, 45. So, if we look at what's happening with diabetes in this country and we want to pick up the largest number of cases, we really have to start looking at those people who show the biggest surge in diabetes, and that's the 45 year and older age group. And so, we recommend that every adult in this country be considered for screening to see whether or not that person is at risk for having diabetes. And the sharp rise in diabetes in this country really justifies looking at this disease in that way. 

NEMA: I understand that being tested is not very expensive and not too time consuming....? 

GAVIN: it's a very simple procedure. I mean the other important change in the recommendations is the fact that we are suggesting that the "gold standard" for making the diagnosis of diabetes be changed from a very cumbersome test, called the "oral-glucose tolerance test", where you have to drink a concentrated glucose solution, and then, over a period of hours, have multiple tubes of blood drawn...you have to be on a certain diet for a number of days...at rest, and so forth. Well, we're making a change to a very simple test...where you fast for 8 hours or more, and you have one tube of blood drawn. A "fasting plasma glucose determination". And that's it. And the screening test is very similar to that...where a person comes in, and gets a simple tube of blood drawn. This actually should be part of every person's general health maintenance, that we should be doing these types of tests, just like we do for cholesterol, just like we measure blood pressure...any of a number of tests that are going on right now, we should be including screening for blood glucose levels.  

NEMA: Another of the new recommendations include lowering the glucose level in the blood that signals the onset of diabetes.... 

GAVIN: This has been, perhaps...in our view, in the expert committee's view...one of the most important recommendations growing out of this reclassification system. New research, looking at big populations, has shown that the damaging effects of high blood sugar in people with diabetes, occurs much earlier than previously acknowledged. If you look at the Egyptian data, if you look at the Pima Indian data, if you look at the general U.S. population data...through three different very large population based surveys, what we learn is that we start seeing a sharp increase in diabetic eye disease, which is one of the things that we are concerned about...at a level of blood sugar well below 140, which was the old cut point. It actually starts to deteriorate after about 110 to 115...and so 126 is now the new number, the compromise number.. which reflects what the consensus is for where we ought to be making the diagnosis of this disease. And that's a fundamentally important downward shift, because it will help us capture people who are out there now, with diabetes, but have been undiagnosed in the past. And this won't create new diabetics, this will simply move people from undiagnosed, into the diagnosed category. 

NEMA: How have the guidelines changed for the higher risk groups... 

GAVIN: Well, one of the things we've found...again by population based research, by following people in whom there seems to be a high prevalence of diabetes...is that we've learned a lot about how this disease behaves in certain groups. In Native Americans, in Hispanic Americans, in African Americans, and in certain Asian American groups, there is more diabetes. But not only is there more diabetes, it occurs earlier...so they get it at a younger age. And when it occurs, it tends to behave in a more aggressive way....so they get more complications, and the complications are more aggressive in their behavior. And for that reason, we've modified the recommendations to say that in those high risk groups, particularly where there's a family history, you may need to start screening earlier, because they may not wait until 45 or older. They may start getting the disease, as often is the case, at age 30, and so we want to make sure we give everybody the best chance of having this disease detected and treated as early as possible, because that's when we know we can do the most to prevent its damaging effects. 

NEMA: What can you say about the prevention of diabetes...to those of us who are at risk...and for those of us whose lifestyles may be taking us in that direction? 

GAVIN: One of the things that we're most encouraged about is that when we talk about early detection of diabetes, we're not necessarily talking about putting people on drugs...changing lifestyles can really do a lot to prevent the disease from progressing...or even prevent the disease from developing, period. And this is the recommendation that's especially for people at risk for diabetes...but it's important for all of us. we're just talking about healthy lifestyles. We should do more physical activity, we should not be smoking cigarettes, we should be watching what we eat, reduce the amount of fat and simple sugars in our diets. And that's what we want people to understand...it doesn't mean going on needles, it doesn't mean taking pills. It means the first and most important thing we want to do - let's live healthier lives....and then we can make diabetes much less of a problem in the American health care system. 

NEMA: Another thing to pass along: you are not destined to have diabetes just because your parents developed it....their affliction may help you avoid diabetes altogether...if you get the message, and take action. Many thanks to Dr. James Gavin of the Howard Hughes Medical Institute near Washington D.C. 

SPOT: 15 years in the prevention of heart disease, stroke and trauma - The National Emergency Medicine Association. This show is just part of what NEMA does. We send out millions of pieces of prevention information to people around the country, give grants to organizations in research, public information and emergency services, and have been instrumental in the creation and expansion of the Chest Pain Emergency Room movement. To play a role, call 800-332-6362. 

NEMA: Thanks for joining us for today's program. If you have any comments or suggestions, contact this station. Or visit our home page at: www.nemahealth.org/...for a look at transcripts of this or past programs, or to find out more about the National Emergency Medicine Association. I'm Steve Girard at The Heart of the Matter.