All was going well with James McNiff’s life insurance application until the underwriter ordered a blood test. It revealed that McNiff’s blood glucose levels were dangerously high—he had type 2 diabetes.

The diagnosis did not surprise McNiff, 67, of Southern Pines.

“I expected I might get diabetes,” says the retired flooring industry executive. “It runs in my family, and I was very overweight when I was diagnosed.”

Diabetes had stricken relatives on both sides of McNiff’s family, including his father, a grandmother, a grandfather, aunts and uncles.

Of the more than 580,000 North Carolinians with diabetes, one-third don’t know that they have the disease, according a 2002 report from the Diabetes Prevention and Control Branch of the North Carolina Department of Health and Human Services’ Division of Public Health. Across the state—and the country—the prevalence of diabetes continues to climb, reaching near-epidemic proportions and mirroring a similarly startling surge in obesity.

What is diabetes?
Diabetes is a disorder of the body’s endocrine system and the process of carbohydrate metabolism—how our bodies convert food into fuel. The body’s primary energy source, glucose (sugar in the blood), is derived from carbohydrates during digestion. After a meal, insulin, a hormone produced by the pancreas, is released into the bloodstream, allowing cells to absorb glucose, which provides nourishment to the body.

In people with diabetes, the body becomes unable to produce or release the right amount of insulin. In some cases, the pancreas stops producing insulin or makes too little to deliver adequate amounts of glucose to the body’s cells. This is known as type 1 diabetes, which used to be referred to as “juvenile” or “insulin-dependent” diabetes.

According to Michael Soboeiro, M.D., a board certified internal medicine specialist with Pinehurst Medical Clinic, type 1 diabetes is believed to develop from a “viral insult” to the pancreas. “The virus knocks out beta cells in the pancreas, so it doesn’t produce insulin anymore,” he says. In people with type 2 diabetes, the body loses its ability to draw glucose from the bloodstream. Unable to nourish the cells, the excess sugar builds up in the blood, eventually passing out of the body through the urine. Sometimes type 2 diabetes is called “adult-onset” or “non-insulindependent” diabetes. “By far, type 2 diabetes is most common among my patients, especially those of Native American, Latino and African American descent,” says Robert Townsend III, D.O., a board certified family practice physician with FirstHealth Family Care Center-Raeford. “Type 2 diabetes definitely is more prevalent than type 1,” Dr. Soboeiro says. “The ratio is about 90 to 10 in the population.”

Robert Towsend, D.O. Michael Soboeiro, M.D.

A weighty problem
Although the risk of developing type 2 diabetes increases with age, the incidence of the disease in children and teenagers is on the rise.

Both Dr. Soboeiro and Dr. Townsend agree that the culprits behind type 2 diabetes—for young and old alike—are an unhealthy diet, physical inactivity, and being overweight or obese.

“The increasing prevalence of type 2 diabetes is the direct result of lifestyle issues,” Dr.Townsend says. “Those most at risk for developing the disease do not watch what they eat and do not get enough exercise.”

According to Dr. Soboeiro, lifestyle modification is the key to preventing type 2 diabetes or delaying the onset of the disease.

“It’s a big challenge to convince people they need to change their habits,” he says. “Most people want to do the right thing, but they find it hard to incorporate healthy habits in their lifestyle. It’s easier to get people to exercise than change their dietary habits significantly, but good health really requires both.”

(For information on how FirstHealth’s Diabetes Self-Management Program can help patients with diabetes make healthy lifestyle changes, see the story here.)

A diagnosis of diabetes didn’t altogether surprise Southern Pines resident James McNiff. The disease runs in his family. McNiff’s diabetes was discovered during a blood test ordered for an insurance application.

After James McNiff was diagnosed, he admits he didn’t drastically alter his lifestyle right away. “I watched what I ate somewhat, but I didn’t follow a strict diabetic diet, and I did not increase my activity levels early on,” he says. “Back then, I just wanted to live my life and not be so strict with everything that the disease controlled me.” For people already living with diabetes like McNiff, a healthy diet and exercise are essential to maintaining good glucose control and preventing long-term health problems associated with the disease. Diabetes increases your risk for cardiovascular disease, kidney disease, blindness and peripheral nerve damage.

“Diabetes is generally a progressive, chronic disease, meaning it lasts for a lifetime and gets worse over time,” Dr. Townsend says. “I have seen new onset type 2 diabetics reverse the course of their disease with strict attention to correcting their lifestyle issues.”

Around 1995, when McNiff and his family were living in Georgia, he joined a wellness center and began working out every day. He dropped 50 pounds and remains committed to physical activity, which he credits for keeping his diabetes under control and keeping other health problems at bay.

“The biggest impact on my health is exercise,” he says. “If I exercise, my blood sugar stays in the normal range for me. In addition to walking three to four miles each morning, I keep busy with woodworking and handyman work. I also help one of my neighbors, a widow, maintain her four-acre property along with my own. The gardening gets pretty physical: cutting down trees and carrying them off, and raking leaves.”

Diabetes during pregnancy Sometimes pregnancy can trigger the metabolic muddle known as gestational diabetes, which occurs in about 4 percent of expectant mothers, reports the American Diabetes Association. “We’re not sure what causes gestational diabetes, but in some theories, a hormone produced by the placenta has been implicated,” says John Bullis, M.D., a board certified obstetrician/gynecologist at Southern Pines Women’s Health Center. “Genetics and obesity also seem to play a role. Women with a family history of type 2 diabetes and women who have had gestational diabetes in a past pregnancy are more at risk for the condition, as are obese women and those over age 35.”

John Bullis, M.D.

Although gestational diabetes is a temporary condition that resolves after childbirth, women who develop diabetes while pregnant face a greater risk of developing type 2 diabetes later in life, according to Dr. Bullis. The National Institute of Diabetes and Digestive and Kidney Diseases estimates that women who have had gestational diabetes face a 20 to 50 percent chance of developing type 2 diabetes within five to 10 years.

“Sometimes, the mother’s diabetes persists after the baby is born,” Dr. Bullis says. “In these cases, we believe the patient had pre-gestational diabetes—type 1 or type 2 diabetes that happened to be diagnosed while she was pregnant.”

Perhaps the most significant health risk of gestational diabetes is having a large baby, which can cause complications during childbirth.

“A large baby may not fit through the birth canal properly,” Dr. Bullis says. “The baby may suffer a broken collar bone or shoulders as a result. There’s also a higher rate of Caesarean sections among women with gestational diabetes.”

Conversely, women with type 2 diabetes who become pregnant are more likely to have a small baby due to placental insufficiency resulting from vascular damage to the placenta.

“Vascular damage within the placenta may result in poor blood flow and inadequate delivery of nutrients to the baby,” Dr. Bullis says.

Making the diagnosis
For all types of diabetes, doctors use simple blood tests to diagnose the disease. A fasting plasma glucose test measures blood sugar levels after eight hours of fasting. During an oral glucose tolerance test, which also is performed after eight hours of fasting, doctors measure blood sugar levels two hours after the patient drinks a glucose solution.

Pregnant women without diabetes or diabetes risk factors routinely undergo a one-hour oral glucose tolerance test between 24 to 28 weeks.

“If a woman has risk factors, such as obesity or family/personal history of gestational diabetes, we usually begin screening at the initial obstetrician visit,” Dr. Bullis says. “We want to catch diabetes as early in the pregnancy as possible.”

A manageable disease
Advances in medicine have enhanced the quality of care—and enjoyment of daily activities—for people living with diabetes.

Since its discovery in the 1920s, insulin has become the most widely used medicine in diabetes care, and doctors today have several types of insulin from which to choose. The newest form, a rapid-acting inhalable insulin approved by the U.S. Food and Drug Administration in January 2006, provides a needle-free option to millions of patients.

Traditional, injectable insulin is available in long-acting, rapid-acting, short-acting and intermediate-acting formulations. These types of insulin are used individually, in combination with each other or in combination with oral medicines, giving physicians and patients a wide array of treatment options at any stage of the disease.

For people who prefer the convenience of an insulin pump, developments in medical technology are making this drug-delivery system even more effective. Some insulins even come in a pre-filled disposable pen.

“Insulin pumps are getting better and better, and I have a number of patients using them,” says Dr. Soboeiro. “Perhaps the biggest advantage of the insulin pump is its ability to free people from having to carry around needles and syringes. They simply press a button, and the pump administers the insulin dose.”

Continuous glucose-monitoring systems represent another technological advance in diabetes care.

“The system will tell you what your sugar is every five minutes,” Dr. Townsend says. “It goes through a catheter in your skin and saves you the hassle of pricking your finger for a blood sample.” From the pharmaceutical industry come new oral combination therapies (pills) for diabetes. As the name suggests, combination therapies blend different types of blood sugar-lowering medicines, such as metformin, rosiglitazone, glimepiride or others, into one tablet. Some of these medicines cause your body to make more insulin, make better use of the insulin it already produces, or decrease the production of glucose. Clinical researchers continue to discover and develop newer generations of diabetes treatments. According to the Pharmaceutical Research and Manufacturers of America (PhRMA) 2005 Industry Profile, some recent innovations include “a protein to promote increased insulin secretions when blood glucose levels are high but not when they are normal and medicines to lessen diabetic nerve disease and complications in the eyes or kidneys.” “When I moved back to North Carolina and started seeing Dr. Soboeiro, he changed my whole medication regimen,” McNiff says. “I take one type of insulin with meals and another before bedtime. I’m also taking metformin twice a day. I’m paying closer attention to my diabetes now, and my glucose control is better than ever.”

ADA-recommended ranges for people with diabetes If you have diabetes, talk to your health care professional about your glucose target range. The American Diabetes Association recommends the following blood glucose ranges for people with diabetes. Glycemic control   A1c <7.0% Preprandial plasma glucose 90–130 mg/dl Postprandial plasma glucose <180 mg/dl Blood pressure <130/80 mmHg Lipids   LDL <100 mg/dl Triglycerides <150 mg/dl HDL >40 mg/dl