Dealing with a chronic disease successfully requires three key things.
1. Understanding the nature of your chronic illness.
2. Knowing what can be done about it.
3. Believing that it is worth your time to do something about it.
That is especially true for type 2 diabetes and the science of that condition is very far advanced and widely misunderstood. One of my personal medical science heroes is Dr Ralph DeFronzo, who is a recipient of the Banting Medal from the American Diabetes Association. “The Banting Medal for Scientific Achievement Award is the American Diabetes Association's highest scientific award and honors an individual who has made significant, long-term contributions to the understanding of diabetes, its treatment, and/or prevention. The award is named after Nobel Prize winner Sir Frederick Banting, who codiscovered insulin treatment for diabetes.” The winner of that award gives the Banting Lecture at the ADA’s annual meeting. This piece is based on Dr. DeFronzo’s Banting Lecture before the ADA.
The main lesson from this lecture that most people don’t understand is that people already have very advanced disease just before they meet the criteria for diabetes. Resistance to the effects of insulin and a decline in the ability to make insulin are the two key defects in the development of type 2 diabetes. The beta cells in the pancreas make insulin and most people don’t realize that beta cell failure occurs much earlier and is more severe than we previously thought. Impaired glucose tolerance is defined by a blood sugar of 140-199 after an oral glucose load. Type 2 diabetes diagnosis requires a sugar level of 200 or greater on this same test. Patients with late impaired glucose tolerance are maximally insulin resistant and they have lost over 80% of their insulin producing capacity before they become diabetic. The further deterioration of glucose control that occurs with diabetes is related to further declines in the ability to produce insulin due to greater loss of beta cell function.
It is also important to remember that the cut points between normal glucose tolerance, impaired glucose tolerance, and type 2 diabetes are arbitrary and artificial. Glucose intolerance is a continuum and there is an associated continuum of risk. The higher the blood glucose, the greater the risk of nerve and eye damage even before diabetes develops. Diet and weight loss reduce insulin resistance and can reduce sugar levels below the level that identifies a patient as diabetic, but this lecture helps us understand that the risk of diabetic complications continues even at these lower glucose levels. Weight loss can also improve beta cell function and increase insulin production early in diabetes and bring glucose levels down to levels less than that required to diagnose diabetes. If you change what you are eating you can lose weight and control your sugar, but most people are not doing that. For most people, an early aggressive approach in the prediabetic stage with lifestyle advice and metformin is the most successful.
The bottom line: even before we reach sugar levels high enough to diagnose diabetes, resistance to the effects of insulin is near maximal and most of our ability to produce insulin is lost. We are far too relaxed in our approach to type 2 diabetes and even prediabetes. We do too little too late! I was heading for diabetes. I was prediabetic fifteen years ago. I lost 70 pounds and started taking metformin. I had read Dr. DeFronzo’s article and knew that I needed to get serious about this problem. There is no such thing as mild diabetes or a touch of diabetes. One of the best things you can do for your health is to take prediabetes or type 2 diabetes seriously and be aggressive in managing it. You can dramatically slow your progression to more expensive drugs and complications.
Another great article! Thanks for all you do!