The challenge of diabetes diagnosis in Hawaii

Rates of people diagnosed with diabetes are growing in Hawaii and the United States. Over 110,000 people have diabetes and it is the 7^th leading cause of death in Hawaii.

Diabetes is a disease which affects a person’s ability to convert food to energy due to problems creating or utilizing insulin.  Insulin is a hormone created by the pancreas that helps with the uptake of glucose (sugar)  by the body’s cells.  The symptoms include excessive thirst or hunger, unexplained weight loss or gain, frequent urination, extreme fatigue, blurry vision, sores that won’t heal and tingling or numbness in the hands or feet. There are many types of diabetes.

• ·        Type 1 diabetes is diagnosed when the person has no ability to make insulin due to a failure of insulin producing cells of the pancreas.  People with type 1 diabetes must take daily injections of insulin and it is diagnosed most frequently in children and young adults. Its onset is often sudden and so diagnosis is rapid after the start of symptoms.
• ·        The most common form of diabetes is type 2 which occurs when a person doesn’t  produce enough insulin or can’t  use it properly. Symptoms from type 2 diabetes can come on gradually over years making it a challenge to diagnose and hard to manage. 
• ·        Other types of diabetes are gestational diabetes which occurs only during pregnancy and pre-diabetes which is a term used for people who have blood sugar levels which are higher than normal but not yet high enough to diagnose as diabetes.

Health risks of diabetes

The problem with diabetes are the complications that can result from the disease, particularly if insulin levels are not managed. Diabetics have a significantly increased risk of cardiovascular disease, kidney disease, nerve disease, blindness, and pregnancy complications.  Adults with diabetes are two to four times more likely to die of heart disease and stroke than adults without diabetes.  Diabetes is the leading cause of new cases of blindness among adults aged 20 - 74.  Diabetes is also the leading cause of end-stage renal disease,  which means the kidneys stopped working well enough for a person to live without dialysis or a transplant. Between 60% and 70% of people with diabetes have mild to severe forms of nervous system damage, contributing to leg, foot and toe amputation risk. People with diabetes are more likely to die of complications from flu or pneumonia and more likely to have  oral health issues and high blood pressure which increases the risk of stroke and heart attack. Uncontrolled diabetes can cause acute life-threatening events, such as diabetic ketoacidosis and coma.

Risk factors of diabetes

Risk for diabetes is determined by certain factors, including ethnic, genetic, physiological, and behavioral. Certain ethnic groups have higher rates of diabetes, including Native Hawaiians, Japanese, Koreans, Filipinos, and Chinese. Age also plays a major role in diabetes prevalence. The CDC estimates that nearly 1 in 5 adults over the age of 65 years has diabetes. Furthermore, nearly 80% of diabetes is diagnosed in overweight and obese individuals, suggesting a strong link between being overweight and the development of diabetes.

Life style component of diabetes

The growing prevalence of diabetes cannot be separated from the rising prevalence of obesity and physical inactivity. According to 2003 Hawaii Behavioral Risk Factor Surveillance Survey (BRFSS) data, adults with diabetes were overweight and obese more than adults without diabetes.  The fat stored around the abdomen, called the omentum, uses large amounts of insulin forcing the pancreas to over-produce insulin so the cells can still absorb glucose from the blood for energy. An oversized omentum is linked to insulin-resistance and type-2 diabetes because it uses so much insulin from the blood stream.  Losing fat around the waist and increasing activity and exercise are ways to minimize the danger of insulin-resistance and onset of type 2 diabetes.

Special problems with ethnic diagnosis of diabetes

Diabetes mellitus is diagnosed based by high levels of glucose (blood sugar) in the blood after fasting for 8 hours.  A level of 126 milligrams per deciliter (mg/dL)  or above, confirmed by repeating the test on another day, means a person has diabetes. The problem is that this method of diagnosing diabetes may only apply to a subset of people with insulin problems. A study on Japanese type 2 diabetics showed that they are typically not obese and their weights are similar to the general Japanese population.  This is contrary to the widely held view that type 2 diabetes is primarily the result of insulin-resistance and obesity.  A rise in obesity preceded the huge increase in type 2 diabetes among the Pacific Islanders, but in Japan there has not been an increase in obesity since the 1970’s and yet the population of diabetics has soared.  In the case of Asian populations, diabetes may be a result of a slowdown in insulin production rather than insulin resistance and diet and exercise may be of little benefit.  Worse, the diagnosis methods, which are based on obese patients, are showing to be inadequate for Asians populations.

Strange relationship between Alzheimers and insulin

One wonders if the slowdown in insulin production is a type of disease that has gone undiagnosed in the past.  Recently, researchers published results showing insulin drugs appeared to slowdown cognitive decline in Alzheimer patients.  Studies have previously shown that Alzheimer patients have reduced levels of insulin in their brain, so a team at the VA Puget Sound Care Center gave Alzheimer patients insulin for 4 months and the results showed they improved in memory tests.  

Stomach operations to treat diabetes

In 2002, a group of doctors in Australia reported that performing stomach LAP-BAND surgeries on their patients with type 2 diabetes put their disease in remission based on their patients’ improved blood glucose levels.  Now gastric bypass, an operation that reduces the size of the stomach and bypasses part of the intestine in order to limit the amount of calories that can be absorbed, is being touted as a cure to type 2 diabetes. It has shown results with 80% of obese diabetics, but surgeons are now doing it on normal weight diabetics.  However, diabetics often go into temporary remission when they sharply reduce their food intake which frequently occurs after surgery on the digestive system. No long term studies have been done yet, so it is unknown if lower levels of glucose may be just an artifact of the reduced number of calories being absorbed and the patient’s diabetes may be substituted for another insulin deprivation disease, like Alzheimer’s.

Conclusion

We wrote this blog to educate ourselves about diabetes because so many of our friends in Hawaii are daily challenged by the disease.  Considering the devastation to a body’s cells when short of insulin, we wonder if using blood sugar levels as the primary method of diagnosing diabetes makes sense. Ethnic differences may mask the disease exposing some in Hawaii to delayed diagnosis and greater health risks.   It may be more important to be attentive to the symptoms rather than rely on a blood sugar test.  And there may be other symptoms like memory loss, that have yet to be identified as the result of the body’s long term insulin shortage.