Researchers Preach Prevention to
Thwart Explosion of Diabetes
Excerpt By Stephen Smith, Miami Herald

How do you stop a killer?

By making sure it doesn't strike in the first place.

After decades of injections and amputations and a constellation of life-limiting complications, the quest to shackle diabetes has shifted dramatically to the realm of prevention.

The need has never been greater: Diabetes is amid a deadly explosion, for reasons that remain oblique to researchers. It's estimated that one of every five Medicare dollars in the United States goes to the treatment of the disease and its consequences.

And there are few places in the nation where the crisis is more acute than in ethnically and racially diverse South Florida. That's because diabetes strikes with disproportionate fury among Hispanics and African Americans.

``The pundits felt, and certainly I did, this is a disease that is exploding in our country and around the world, and it is a disease diagnosed late and difficult to treat well,'' says Dr. Ronald Goldberg, an endocrinologist with the University of Miami's Diabetes Research Institute. ``It is a disease that we need to stop from happening in the first place.''

So scientists like Goldberg increasingly devote their time -- and their research dollars -- to studies dedicated to preventing diabetes, a disease with 16 million Americans on its roster. At a time when inhaled insulin is within a year of widespread use and insulin pills loom five years away, there is renewed urgency focused on the pursuit of lifestyle and pharmaceutical solutions for the condition.

The Diabetes Research Institute, for example, was among 27 centers in the nation that participated in a landmark study that yielded such startling results it was stopped early so that the gospel of prevention could be promulgated.

And now the institute stands at the dawn of another trial, research that will examine whether two drugs -- in concert with lifestyle changes -- can halt diabetes in up to 75 percent of cases.

Iliana González is testament to the power of prevention. Her mother had diabetes. She is at risk of developing diabetes.

`VERY SCARY'

``The diabetic patient goes through a lot -- pain and complications and transplant,'' González says. ``If they don't take care of themselves, they lose a finger or a toe. It's very scary.''

She should know -- González works at UM's diabetes clinic in the medical records division. So when she heard about something called the Diabetes Prevention Program -- the historic study that ended earlier this year -- it didn't require much persuasion to get her to participate.

González altered her diet. Out with the sweets. In with more vegetables and fruit. Out with red meat. In with white meat. Out with a sedentary lifestyle. In with a 20- to 30-minute stroll five days a week around a park near her West Miami-Dade home.

``It's hard, but you do it,'' González says. ``You see all of these good things, and you want to eat them, but you say, `No, I have to watch myself.' ''

And, so far, González has succeeded in staving off diabetes.

Her experience conveys this message: If they take care of themselves, eat the right foods, engage in a little exercise, then other potential victims could stay beyond diabetes' thrall.

A NEW VIEW

It is an understanding that has revolutionized the way physicians and patients view the disease.

``Perhaps diabetes is not inevitable in people at risk -- in some ways, people have a choice about their future health,'' says Dr. Diane Krieger, medical director of the Diabetes Care Center at South Miami Hospital. ``And it does not necessarily require a dramatic lifestyle overhaul but a gradual and deliberate attempt to increase activity and improve food consumption.''

This always seemed to make sense. But until the Diabetes Prevention Program came along, researchers were bereft of scientific data to persuade the doubters.

NUMBERS SAY A LOT

Now, they have the numbers.

They knew the stakes were substantial. Type 2 diabetes -- accounting for as many as 95 percent of all cases in the United States -- is on a three-decade rampage, its incidence tripling.

OBESITY FACTOR

Some of that increase may be attributable to better detection. But experts implicate an unparalleled surge in obesity as the prime suspect.

Thus, the Diabetes Prevention Program emphasized changes in lifestyle, with some of the 3,234 study participants receiving intensive counseling and monitoring. Others received less intensive guidance, while another coterie in the study was placed on medication.

The results stunned researchers -- and prompted a ruling that it was no longer ethical to continue the study, acknowledgement that the findings were so persuasive that they should be implemented immediately.

The conclusions: The participants who engaged in intensive lifestyle changes reduced their risk of developing type 2 diabetes by 58 percent. That eclipsed, convincingly, the 31 percent reduction for people who took a drug called metformin.

So what did those lifestyle alterations incorporate?

EXERCISE, DIET

Turns out it was nothing dramatic -- or traumatic. The changes included half an hour of physical activity a day, along with a healthier diet.

``When you talk about exercise, people think they have to become athletes. They don't have to do that,'' says Dr. Eugenio Angueira, an endocrinologist at Mount Sinai Medical Center & Miami Heart Institute. ``Just do something -- get off that couch.''

And while that sounds simple enough, in practice it can prove daunting.

``People have good intentions but find change very difficult,'' Krieger says. ``The very rare person will take the advice and run with it. The majority have great intentions but real difficulty.''

That's why doctors remind patients that they're not being asked to become wafer thin. Instead, they tell them that shedding 10 percent of their weight can have a remarkably salutary effect, reducing levels of blood glucose and blood pressure.

HEART-ATTACK RISK

The latter is critical, because diabetics are in substantial peril of suffering heart attacks and strokes. In fact, research has demonstrated that diabetics have as much of a chance of suffering a heart attack as a nondiabetic who has already had a heart attack.

Still, even with that arsenal of knowledge, some people find lifestyle changes too onerous. That has inspired a new study called DREAM -- Diabetes Reduction Assessment with Medication. UM is among the research centers in North and South America starting the trial.

``We know you can ask people to make a change in their lifestyle but not all of them will do it,'' UM's Goldberg says. ``So should we take the next step and medicalize you by prescribing medicine?''

Two drugs will be used in the DREAM study: ramipril (trade name: Altace) and rosiglitazone (trade name: Avandia). Ramipril is a blood-pressure medicine that in studies showed a propensity for reducing the prevalence of diabetes. Rosiglitazone was concocted with the specific intent of abating diabetes.

The drugs will be given separately and in tandem, and some patients will get dummy pills.

UM researchers hope to engage 100 South Floridians in the four-year study.

And they hope to engage them in lifestyle changes that will reverse the course of a disease expected to claim nearly 200,000 lives this year.

``Most people get scared when they get the diagnosis,'' Angueira says. ``They also know they will have to stop doing things they like to do, stop eating certain foods.

``But now we have knowledge that can encourage them that this is something that can be prevented.''

Reference Source 107

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