Search for tag: "prediabetes"

Interviewer: How exercise is key for managing prediabetes and diabetes by improving the body's ability to use sugar. We'll talk more about that next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Tim Graham is a diabetes expert. He's also an assistant professor of medicine, biochemistry and nutrition at University of Utah and is the medical director for the diabetes, obesity, and metabolism programs here at University of Utah Health Care.

I want to drill down a little bit into the importance of exercise for prediabetes, those who have been diagnosed with it, and diabetes, almost more important than nutrition, is what I've heard. Is that accurate?

Dr. Graham: Yeah, it's at least as important. We tend to, in our society, focus so much on body weight, and partly because we look at skinny people and they're the people that we see in Hollywood.

Interviewer: They look so healthy.

Dr. Graham: Yeah, they look so healthy, and yet without activity you're not so healthy. So it's not just about body weight, but it's also about keeping your body moving.

Really, prediabetes and diabetes are diseases of glucose metabolism. Normally, when you take a meal, your body produces insulin from the pancreas. Insulin circulates through the blood and tells the muscle to take up glucose so that right after a meal you might have a rise in glucose, but then when insulin kicks in, it causes the blood sugars to go down pretty quickly, because it tucks it away into muscle where you can use it later as glycogen when you're exercising.

The problem with diabetes is not necessarily that people don't make enough insulin, although in the case of Type 1 diabetes, we do see that. We can talk about that as a separate issue, but Type 2 diabetes, which is by far the most common type of diabetes, is a problem where people don't respond normally to insulin.

You make the insulin, in fact, you tend to make more insulin than the average person, but your body just doesn't respond normally. The skeletal muscle won't take up glucose in response to insulin. We call that condition insulin resistance, and that's really the classic Type 2 diabetes type problem.

One of the beauties of exercise is that it bypasses that defect by directly stimulating glucose uptake by muscle, so even if your insulin isn't working great, you can get your skeletal muscle to take up glucose more avidly or more efficiently just by exercising on a regular basis.

Interviewer: Can that condition be fixed by exercise, or is it just a workaround?

Dr. Graham: It's both. If you are exercising regularly and you have diabetes, you'll notice your blood sugars are more well-controlled with less and less insulin. Ultimately, if you have prediabetes and you can exercise regularly, you very likely will prevent yourself from developing the worsening condition of diabetes.

Interviewer: So it's a condition that can be taken care of.

Dr. Graham: By all means, yeah.

Interviewer: What kind of exercise are we talking about? People are busy; people don't like to be in pain.

Dr. Graham: There's been a lot of work done to figure out exactly what is enough exercise to have an effect. Frankly, as little as 150 minutes per week, now, that sounds awful, 150 minutes, but you break that down . . .

Interviewer: Sounds like a lot.

Dr. Graham: We're not talking about going to the gym and working out to the point where you're exhausted, we're talking about some brisk walking five times a week.

Interviewer: Or getting out in the garden or some house . . . I was vacuuming the house this weekend and I was sweating moving the furniture and bending down.

Dr. Graham: Yeah, truly. Anything that causes your heart rate to go up for a sustained period of time, causes you to sweat, most likely is having a good benefit from the standpoint of diabetes prevention.

Interviewer: So exercise, key for managing diabetes, for reducing your chance of getting it. If you have been diagnosed with prediabetes, to backing that off.

Dr. Graham: Absolutely.

Interviewer: Anything else that I need to know about exercise?

Dr. Graham: If you already have diabetes and you've had it for a sustained period of time, we do recommend that people get evaluated by their physician before they undertake a more rigorous exercise program. That's only because when you've had diabetes for a while, there's an increased risk that you might develop some heart problems, so we do recommend that people go out and at least get some evaluation to make sure that that's not a risk factor that they have before they undertake more rigorous exercise.

But the vast majority of people don't fit into that category who are contemplating starting exercise. Many people will have prediabetes, and frankly, they should feel comfortable just going out and getting it done.

Interviewer: If a little bit of exercise is good, is a lot of exercise even better? Do the benefits increase linearly?

Dr. Graham: They actually do. There are always people who we can see that develop syndromes of over exercise and sometimes that's associated with bulimia and other problems. But in most cases, people exercising more intensely for longer periods of time will be beneficial for people overall.

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Interviewer: Pre-diabetes. What is it, what are the symptoms, and what can you do about it? Odds are you have it. We'll talk about that next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Tim Graham is a diabetes expert at University of Utah Health Care. As a matter of fact, he's the Medical Director of the Diabetes, Obesity, and Metabolism Programs for University of Utah Health Care. Pre-diabetes: epidemic? Is that fair to say?

Dr. Graham: Oh yeah, that's about as fair to say as anything you could ever call an epidemic in all of medicine. So we've got right now about 40% of people in the United States affected with pre-diabetes, and probably less than 10% of those people even know that they have it. So the vast majority have no idea they have this condition. It is asymptomatic so people really don't have symptoms that would prompt them to go see a doctor to get checked out.

Interviewer: And I have to say, I consider myself to be a fairly healthy individual. I walk my dogs a half hour each day. I watch what I eat, for the most part, but I had my glucose done and from what I understand I have pre-diabetes. It was a shock to me.

Dr. Graham: Yeah, yeah. You just shared that with me that your blood sugar was exactly at the level where we call people as having pre-diabetes. The condition is called impaired fasting glucose when you have a blood sugar, a fasting blood sugar of 100 milligrams per deciliter or more. And if you get up to 200 we call it diabetes.

Interviewer: And what does that mean to me? What road am I on?

Dr. Graham: Well, the problem with having been diagnosed with pre-diabetes is you've got roughly, over a five year period, you've got a roughly 30% chance of developing diabetes itself. And so even in the short-term, and to me really five years is a fairly short-term. It's looking out a few years. You've got a good chance of getting diabetes. Now, the important thing is that this can be completely prevented. It can be intervened on, especially by taking on some lifestyle modifications. So if you could do some changes where you lost a few pounds and started increasing your activity, you could prevent it by 50 to 70%.

Interviewer: You're kind of like the ghost of Christmas future right now, aren't you?

Dr. Graham: That's right.

Interviewer: "This is your fate unless you change your ways." So let's talk about pre-diabetes. It means you've got a pretty good chance of having diabetes and that's not fun.

Dr. Graham: No, it's not. I mean, if you haven't had a relative with diabetes, the problem is that the blood sugar elevation that you get with diabetes damages many different tissues. So it causes eye problems. It causes kidney problems, and it causes nerve problems. The nerve problems can lead to amputations. The eye problems can lead to blindness. In fact, diabetes is the number one cause of preventable blindness in the United States. And the kidney problems can lead to dialysis. So it's a really miserable set of things that you can eventually develop if you develop diabetes. Also, it increases your risk of heart attack and stroke dramatically.

Interviewer: So it's such a big deal, as a matter of fact, that here at the University of Utah Health Care that there is a whole program now dedicated to identifying and helping people deal with pre-diabetes.

Dr. Graham: Yes, that's right. Right now we are working with our community clinic physicians to identify people at highest risk and start screening people across the board. So if you have any concern based on your weight, your lack of activity, or you've got a strong family history of Type II Diabetes, I would really encourage people to talk to their physicians.

Interviewer: Even if you don't, because I have none of those things. I actually had another physician tell me, "I don't understand why this physician's doing this test on you. You look like you're a healthy guy. How old are you? It's pointless," but it wasn't.

Dr. Graham: You know, you're sort of like the poster child of the sort of movement for universal screening. It's exactly patients, like you, who don't even meet the sort of classic risk factors who probably make a good argument for why we should be screening the whole population.

Interviewer: So you go into your physician, you should probably request what type of a test?

Dr. Graham: Typically, we start with two things. One is a fasting glucose and the other is a hemoglobin A1C. Some people call that last one an HBA1C. So the fasting glucose can tell you, basically, when you're not eating what your blood sugar levels look like. The hemoglobin A1C, however, gives you information about what your blood sugars look like over a three-month period. So if you've been high after meals, the hemoglobin A1C may pick that up whereas a fasting glucose won't really give you that information.

Interviewer: So get those tests done. If they come back as they did for me, then exercise, dietary things that you can do to correct that. And there are probably a lot of resources on the web to find.

Dr. Graham: So we really like to start people with a formal lifestyle intervention program. So the old days of the doctor saying, "Hey, you need to exercise more and eat better," and then sending the patient out the door are over. So what we now have are programs that we get people involved with. They're community-based programs. The one that we run here is a version of the National Diabetes Prevention Program. You'll sometimes hear the term "DPP" and we're the first program of this sort in the state of Utah. We're actually backed by the Centers for Disease Control and the NIH in our efforts to do this.

And what it involves is people coming on a weekly basis for about 16 visits where they learn healthy eating approaches, exercise approaches, stress reduction approaches. And then they continue to follow up with the program for a total of one year. And that program alone has been shown to reduce the development of diabetes by about 50% over a three to five year period. And then in older people, over the age of 65, by 71%. So it's pretty dramatic.

We also have medications. One of them is Metformin that can be taken, either in conjunction with that or alone for people who may not be able to adhere to the lifestyle modification. But we really think people should be doing the lifestyle.

Interviewer: As the poster child, I'm going to go ahead and say this. I understand nutrition. I understand how to eat healthy. These are things that I get. I understand exercise. I used to be a trainer at a weight room and never expected that it would happen to me. I don't want to freak people out, but I think it's just a good thing to know so you can start making some lifestyle changes. Like, my job right now I sit a lot. I don't really move around a lot. I get home, I sit more.

Dr. Graham: And that's a really underestimated problem in the United States. So there are people who are not obese or not even overweight who may eat fairly healthily, but at the same time because of their significant amount of inactivity as well as the effects of aging, you can develop pre-diabetes.

Interviewer: Are there any final thoughts that you have, anything that I forgot to ask you that you feel compelled to say, that you feel our listeners should know?

Dr. Graham: Yeah, you know, this is one of those rare things where if you get it, it's not too late. You can actually reverse the disease process. So I think a lot of people fail to take action on their health because they almost dread finding out they've got a problem. This is one of those situations where you want to know if you have this problem because you can really take steps that will make a huge difference.

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Research indicates that if kids are overweight at 5 years old, they have a pretty good chance of being obese adults.

You've heard me talk about it before. Obesity is becoming a really big problem for kids. And there's a lot of things that you need to remember. Obese kids are at risk for diabetes. They have high cholesterol. I see kids already, kids that aren't even 10, and they have insulin resistance, which is pre-diabetes. They have high cholesterol, high triglycerides. I've seen kids who are barely 10, barely into double digits, and they have triglyceride levels double what an adult should have.

If your child is obese and has asthma, it's going to make their asthma worse. A lot of kids will complain that they're short of breath because they're carrying so much weight. They'll have back pain, knee pain, things like that, and they just can't keep up with other kids. So that's the physical problems that go along with obesity.

The psychological ones, that too, a lot of kids who are overweight, they aren't liked by many kids. They're teased by many kids, bullying, and they don't feel good about themselves. You know, it really weighs on their self-esteem.

So it's important as a parent that you pay attention to this and especially pay attention before they become kindergarteners. See your pediatrician and ask them, you know, "What is my child's weight, what is their height, and what is their body mass index?" All kids over 2 can have their body mass index calculated, and it's just a math formula. It takes their height and their weight into consideration, and it comes up with a number. You need to look at their percentage for their body mass index, and if they're over 95 percentile, they're considered in the obese category.

So a new study came out in "The New England Journal of Medicine," and it showed that half of childhood obesity occurred in children who had been overweight during the preschool years. One thing it pointed out was that kindergarteners who were heavy babies, which is 8.8 pounds or more at birth, were actually more prone to being overweight toddlers and overweight kindergarteners.

We usually associate healthy babies with chubby babies. And the realism is I'm not surprised at this study. I'm seeing a lot of kids who are overweight in their toddler years, who get to just graze all the time with eating, whose parents, you know, they think that they just need to constantly be eating for growth. And actually, kids normally go through what's called the toddler appetite slump. Between ages 1 through 5, they just don't eat that much. They're not growing like they were in the first year of life. They're not growing like they will be during their second growth spurt around the kindergarten, first grade years. So they don't need as many calories in as they did before, so they normally are going to thin out by age 4.

For kids who are overweight before kindergarten, it's like they've already gotten their destiny predetermined. One-third of kids who are overweight in kindergarten were actually obese by eighth grade. I mean, that's when they're around 11 years old. And the concerning thing is almost every child remained that way.

So you don't want to wait until they're, you know, in later elementary years or in middle school before you start going, "Hmm, my child looks a little bit more overweight than some of these other kids." You actually want to start paying attention when they're in preschool. See how their weight is in preschool, because that's going to tell you what things are going to be like once they get older.

Once obesity is established early in life, it actually tracks through adulthood. The only time there's really exceptions is when you make a conscious effort to change the eating habits and the activity habits of the children that you're concerned about.

For a lot of kids there is concern about, you know, what is the ethnicity? You know, everyone says, "Oh, well, I'm from this type of ethnic group, and we always are big-boned people." Or, you know, same with race or family income. A lot of people say, "Well, I don't have the family income to be able to afford all these healthy foods, so I'm going to feed them what I can because I want my children to eat." But, regardless, a lot of people say, "Well, that's how it is in my family." But the truth is, after age 5, those factors no longer affect their risk for being overweight in the later years.

So what parents really need to do is focus on checking their child's growth from early on, seeing how they are on the growth curves. And again, your pediatrician will tell you what their growth is, their weight, their height, and, after age 2, their body mass index at every single well visit.

Parents also need to pay attention to what your child is eating and their eating habits. You want to make sure you're instilling healthy eating and activity habits early on before there's a problem. And if you're worried that there might be a problem, the study reinforces that genetic influences do show up early in life, but exercise and a healthy diet can actually reduce the effect of the genes. You can actually overcome your genetics, to a point. Unfortunately, you can't change your genes. You can change how you eat and how you exercise.

So the important thing is to prevent the problems from happening rather than reacting to the problem once they've already happened. Pay attention to 5210, five servings of fruits and vegetables a day, two hours or less of screen-time, television, computers, video games, one hour of physical activity, and it doesn't have to be one hour all at once. You can do 20 minutes here, 10 minutes here, 5 minutes here, round off with a half an hour, just being active. And finally, zero sugary drinks. That includes juice, that includes soda. You will be shocked to find out how much sugar and how many calories are in a 20-ounce bottle of soda or a 12-ounce cup of juice. It's as much as a candy bar. So eliminating the bad stuff like that from the diet, making them treats instead of daily or weekly parts of your diet can actually go a long way to prevent the problems of childhood obesity.

If your child can make it through their first five years at a healthy weight, the chances that they will remain at a healthy weight for the rest of their lives really improves. So it's worth making the effort early on to give them the best start in life that you can.

updated: December 6, 2021
originally published: March 4, 2014

Interviewer: There are nearly 80 million Americans with pre-diabetes, an often unrecognized and dangerous condition that put patients at risk for developing not only diabetes but also heart disease and stroke.

Dr. Timothy Graham, Director of the Utah Cardiometabolic Risk Reduction Clinic treats and researches the condition. Dr. Graham, at your clinic you assess patients for pre- diabetes. Why is this important?

Dr. Timothy Graham: Up to 30 to 40% of the general population has pre-diabetes. And the problem with actually getting to the point of having pre-diabetes is that you are then at a five to 10% risk per year of progressing to diabetes.

And what I try to emphasize to my patients is that by the time your blood sugars have risen to the point where we diagnose you with pre-diabetes, you have already had a process of disease in place that may have lasted for one or more decades. And there are other risks that are attendant with the high glucose levels.

So, for instance, when someone comes into the clinic newly diagnosed with pre-diabetes or even early Type 2 diabetes, many of them will already have signs of congestive heart failure or have damage to their blood vessels that might put them at higher risk for heart disease or strokes. So the earlier we can diagnose and start preventative treatments and medications, the better we think the outcomes will be in the long run.

Interviewer: So what exactly is the difference between pre-diabetes and diabetes?

Dr. Timothy Graham: Now, I think what's important to recognize is that the fundamental aspects of physiology that lead to the sort of less severe elevation of blood glucose and pre- diabetes are the exact same ones that lead to the more severe elevation in diabetes. So it's really just should be looked at the stage of the disease process rather than a distinct identity.

There is no doubt that everything that goes into creating pre- diabetes is exactly what continues and gets worse to create diabetes. It is true that by the time an individual has diabetes the disease process is perhaps more advanced and harder to reverse.

Interviewer: So remind us of one of the basic mechanisms that are in play here about what's the relationship between blood glucose levels and insulin and what goes wrong.

Dr. Timothy Graham: Generally speaking, when we eat a meal we have blood sugar that comes from our gut, from our intestine. It enters by absorption into our bloodstream. And in our bloodstream it is sensed by cells in the pancreas called beta islet cells. These cells are designed to do nothing else but make insulin for the most part, and when glucose floods into the body they know to secrete insulin. The insulin then circulates through the body and acts primarily at two or three places.

Primarily in the liver, insulin acts to turn off glucose production. When we're not eating, the only way we typically get glucose in circulation is by what the liver makes.

The insulin that floods into the system after a meal also induces uptake of glucose into muscle where it's stored as a substance called glycogen. And a certain amount also goes into fat or adipose tissue where it's used to synthesize actually triglycerides which are a storage form of fat.

So insulin kind of acts in these three different places to essentially lower your blood sugar levels after a meal, first by tucking the glucose into muscle and fat, and secondly by turning off the production of glucose by your liver.

Interviewer: What happens if pre-diabetes is not treated?

Dr. Timothy Graham: So one of the defining features of both pre-diabetes and diabetes, and when I talk about diabetes here, I mean Type 2 diabetes. In this country and in most other countries throughout the world 90% of people who have diabetes have Type 2 diabetes. And Type 2 diabetes is specifically defined by the presence of insulin resistance.

And what that means is your pancreatic beta cells can make insulin just fine, but when that insulin is produced and goes into circulation, it does not act effectively in liver, muscle, and adipose tissue to do what it's supposed to do. And that's because of molecular defect inside the cells that make up those tissues.

What's important to know about insulin resistance is that it varies dramatically from person to person. We have very good quantitative ways of measuring it and that a given individual can be insulin resistant for many years before they develop pre-diabetes or diabetes.

And it's generally been a black box up until fairly recently, that is, we've never really been able to predict among the insulin resistant people who will develop pre-diabetes or diabetes and when they will develop it. But we're changing that now because we're starting to look at the other pieces of the puzzle that go into the actual disease process.

If you think about it, if you're insulin resistant, the response of the body is to make more insulin. So if I have a block to the ability of this hormone to lower my blood glucose levels, the glucose levels stay higher and they keep activating more production of insulin by the pancreas. So the average person with pre-diabetes and most people with early stage Type 2 diabetes will have much higher insulin levels than you or I will.

Interviewer: I believe there's been quite a rise in diabetes in the American population over the last 10 to 20 years. What accounts for that?

Dr. Timothy Graham: So I think it's multi-factorial. There's no doubt as a nation we are more obese. So much so that right now, I believe the most recent 2012 statistics would show that nationwide 60% of the population is either overweight or obese. So it's more common to be overweight or obese than it is to be no which is kind of shocking when you think about it.

Now there's an exceptional line of evidence that supports that excess fat on the body leads to insulin resistance which in turn leads to the development of high blood sugar in diabetes and pre-diabetes. I think what's fascinating is that coupled with this obesity epidemic is an epidemic of inactivity. We probably all see that our kids play outside less than they used to. This time spent not active is, in fact, an independent risk factor even if we control for body weight.

I would say that there's also a less understood transgenerational effect that is fueling the epidemic of diabetes right now. For instance, if your mother was obese or insulin resistant during her pregnancy, even if she didn't have gestational diabetes, you are much higher risk for developing pre-diabetes or diabetes later in life.

And this may be a cumulative effect from generation to generation. Plus finally, there's very good evidence that some of these compounds, like phenol A and others, can have direct effects to sort of program the metabolism of children in utero and in their early childhood so that by the time they're adults they're more prone to diabetes. That's kind of an unspoken about issue, but it really there and it's pretty much acknowledged by people who study environmental health.

Interviewer: There are so many factors that could be influencing the development of diabetes. How do you even begin to approach the problem?

Dr. Timothy Graham: To me there's two ways to react to that. As a clinician, one wants to throw one's arms up in the air and say, "Wow. This is just too big. We can't fix this. All we can do is just sort of hold our head above the water and tread water."

But as a basic scientist I feel like understanding each of these mechanisms as critical because if we can drill down to understand exactly how each of these insults, if you will, leads to the disease. To me if we understand that sort of set of molecular mechanisms, we can actually manipulate them to our benefit.

So, for instance, if we find that a specific environmental toxin activates a certain pathway, it would not at all be inconceivable for us to design a medication that counteracts that, or improve manufacturing processes so that that toxin is eliminated or both.

So the more we understand the molecular level about this process and the various piece of it, which are many, the more opportunities there actually are and the more we understand how we might be able to actually interfere with the process that finally leads to Type 2 diabetes.

Interviewer: What motivates you to look at this problem so carefully?

Dr. Timothy Graham: There really are no approved medications for this. Even the oral medications we have for Type 2 diabetes tend to be somewhat plagued by concerns about their effects on the cardiovascular system. So if you sort of look at the field as a whole, there's an urgent need to develop new approaches to treating the problem.

I think what really excites me is there are so many untapped areas where we can start to come up with new strategies. So, for instance, I mentioned earlier the idea that fat is this major hormonal organ that produces all sorts of substances. Well, if we come back to the basic observation that the strongest association we see in clinical medicine with Type 2 diabetes is with obesity, then it seems like fat is a pretty good place to start.

So I really directed my attention as a basic scientist understanding how fat cells work, what they product, and how they can interfere with that process. I firmly believe that the work we're doing here at the University of Utah in my lab and in other labs like mine here in the Molecular Medicine Program and in the Division of Endocrinology. I believe as a group we're all putting together entirely new ways and approaches to coming up with new treatments for Type 2 diabetes prevention as well as reversal.

updated: November 16, 2021
originally published: January 24, 2014