Diabetes is the #1 cause of end stage renal disease, blindness, and non-traumatic limb amputation in the developed world. Those with diabetes are two to three times more likely to die from a heart attack.
Yet, Type 2 diabetes is a disease of lifestyle, one we can largely prevent. The problem is that we’re waiting too long –until someone is diagnosed with disease to talk about lifestyle modifications.
This is like asking a person to run up a steep mountain pass.
By the time someone is diagnosed, their cells have been malfunctioning for decades. The insulin resistance that causes Type 2 DM builds up over many years. As part of diabetes management, doctors are taught that lifestyle changes are important. Yet asking someone who already has Type II Diabetes to make lifestyle changes is very difficult.
Type 2 diabetes is nasty, and unfortunately it’s growing. My home of New Orleans is in the Diabetes belt, which overlaps with the “obesity belt.”
Diabetes and obesity frequently overlap, because obesity causes some of the pathologic changes that lead to insulin resistance.
What happens inside our cells?
Due to the buildup of glucose within the bloodstream, both the outside and inside of our cells start to malfunction. Excess glucose in our bloodstream sticks to things like hemoglobin. Glycosylated hemoglobin is what we measure, hemoglobin A1C. These products build up and over time cause damage to small and large blood vessels.
The leading cause of death in Type 2 diabetes is Myocardial Infarction, or heart attack. As I mentioned earlier, diabetes leads to many other problems like strokes, limb amputations, kidney disease and blindness. Once someone has diabetes it’s much harder to prevent the progression.
Hospitalizations with COVID were six times higher, deaths were 12 times higher for those with underlying conditions, including diabetes.
The malfunctions within our cells build up over time -- let me show you what happens.
A Brief History of Insulin Resistance
Both Type 1 and Type 2 Diabetes Mellitus are diseases of insulin. Insulin signals the cells of the skeletal muscle and adipose tissue to increase their expression of glucose transporters. Without insulin, the cells can’t bring glucose inside. Glucose is needed within our cells to fuel our metabolism. Some tissues do not require insulin to bring in glucose including the brain, red blood cells, kidneys, cornea and GI tract.
In Type 1 diabetes the pancreas stops making insulin. Most commonly due to autoimmune disease. Those with Type 1 diabetes must take insulin in order to survive.
In Type 2 diabetes, insulin resistance builds over time. This means that even though insulin is released by the pancreas, the cells do not increase their expression of glucose transporters. The expression of GLUT4 transporters is hindered for various reasons. Glucose in our bloodstream can’t get into the cell.
This contributes to a cascade of events
- Skeletal and adipose tissue cells are not getting enough glucose due to lack of transporters
- Cells with glucose-independent transport get excessive glucose (kidneys, brain, RBC)
- The blood glucose remains high so the pancreas secretes more insulin.
- Over time the pancreas gets tired, and the insulin-producing Beta Cells sometimes stop producing insulin.
For this reason, those with long term T2 DM may require insulin after years with the disease. The management of diabetes involves both drugs and lifestyle changes.
How Medicine Approaches Diabetes
In medical school we learned that lifestyle changes are more effective than drugs for treating Type 2 diabetes. We spent most of our time learning about the pathophysiology of diabetes and the drugs to manage diabetes. We didn’t discuss specific lifestyle modifications.
We did learn how diabetes disproportionately impacts low income areas. There are tremendous health disparities in diabetes. The costs of drugs can be prohibitive. When patients require insulin, they need it for survival. Early dietary and lifestyle changes cost magnitudes less than insulin and other drugs later. It's essential that we weave lifestyle modifications into our thinking about longevity.
Why We Need to Rethink Our Approach to Diabetes
It’s crucial that we talk about diabetes early, before we have symptoms. Given the overabundance of cheap processed food, everyone is at risk for developing diabetes. For years your body develops insulin resistance, which we typically wouldn’t quantify. Our lab tests typically measure blood glucose and not insulin. If your body needs more insulin to normalize its blood sugar it’s slowly becoming insulin resistant. One in three Americans is insulin resistant, and 8 out of 10 don't know it!
Measures of insulin resistance would require measuring both glucose and insulin after the ingestion of glucose – similar to the typical glucose tolerance test with the addition of insulin.
The key to prevention is making lifestyle changes early. Because the body becomes more insulin resistant over time, making changes earlier is important and can prevent disease later.
Behavior Change Is Harder Than Taking A Pill
Let’s be honest, lifestyle modification is hard. There’s no key that can unlock our ability to make changes. And the changes necessary for me might not be appropriate for you.
It takes knowledge, accountability, and commitment. In many ways, taking a pill is easier than trying to change your way of eating.
I like to make long-lasting changes by developing new habits. We do many things each day automatically. For example, I wake up, use the bathroom, brush my teeth, make tea and take my dog Cookie out for a walk. When we incorporate a new behavior into our existing routines, over time it becomes a habit. Last year I decided to add meditation to my morning, so after I make tea and take Cookie for a walk, I meditate.
In my years of working with people on changing their diets, I’ve learned that the best way to approach change is small. Look for a small change that fits with your existing routine, and decide exactly where and when you’ll do it. For example, if you want to add more activity to your day, start with a ten minute walk. Plan your walk with an activity in your daily routine, like breakfast. Then get specific, “Immediately before breakfast, I will walk for 10 minutes around my neighborhood.” A bonus to boost your accountability is to use any simple tracking method, like a checkbox on your calendar.
This year we made a small change at home in my children's sugar intake. The American Pediatric Association recommends less than 25g per day of added sugar intake for kids over 2 years of age. We started reading the labels on their snacks and desserts. My son Dylan was astounded at the added sugars in snack bars, ketchup, and crackers. Now they choose where to get added sugars. They LOVE hitting their daily goal.
I hope that in the future more physicians will be trained in habit science. Behavior change is fantastic way to empower patients to impact their health and longevity.
What You Can Do Now
When thinking about your longevity, the behaviors that prevent diabetes also prevent heart disease, obesity and some types of cancer. Our health is holistic and improving one aspect will optimize the others.
For diabetes, daily exercise is key. Physical activity increases the expression of glucose transporters in skeletal muscle, increases glucose utilization, increases the breakdown of fat, and strengthens our heart. Over the long term this means less glucose resistance, so you are less likely to develop diabetes.
Nutrition is a complicated subject. The simple advice is to limit added sugars and eat whole foods. I typically tell my clients to make half their plates vegetables. Eating lots of vegetables helps us with fiber, which slows glucose release into the bloodstream.
Unfortunately fat has gotten a bad reputation over the years. Fats are necessary for cell growth and repair and many cellular activities. Fats are also used as fuel, especially by skeletal muscle and the heart. Choose from fats that are mostly unsaturated, but some saturated fats are fine too.
The above is a small start to help you make changes now. In future posts I will expand on nutrition and exercise.
In summary, eat foods in whole form, eat mostly plants, and limit things with lots of junk. And remember to read labels. Many foods contain sneaky added sugar.
Small But Mighty
In my future practice as a physician, I will continue stress the importance of diet and lifestyle for all my patients. I am encouraged by the awareness of the importance of lifestyle amongst many medical students.
You can invest in your future by making small changes that improve your lifestyle. Add a quick salad to your lunch. Incorporate that ten-minute walk into your evening. Or just eat an apple a day. No change is too small.
The impact of a small change done over the long term is huge.
Interested in more?
I developed a program to help people make small changes in their life that stick for the long term: The Balanced Healthy Path Method. The course helps you to make changes in four areas of your life: Nutrition, Activity, Stress Management and Sleep. When done together the results are powerful. When you stop striving for perfection and strive for your own balance, you’ll feel great. I’m delighted to be able to help you on your journey, one step at a time.