Andy, More good news for LGND on the front page of the NY Times:
June 24, 1997
New Guidelines Issued for Diagnosing
Diabetes
Graphic
Is Your Blood Sugar too High
By DENISE GRADY
evels of blood sugar that have long been accepted as normal are
actually too high and should be considered a sign of diabetes,
according to new guidelines issued Monday by the American Diabetes
Association and endorsed by federal health authorities.
The guidelines call for testing all healthy people age 45 and older -- about
77 million Americans -- every three years, and are expected to lead to
the detection of 2 million new cases.
Under the guidelines, testing would start earlier and be done more often in
people with higher risk, including those who are obese, black, Hispanic,
American Indian or closely related to someone with diabetes.
The new guidelines, announced at a medical conference in Boston, have
been endorsed by the Centers for Disease Control and Prevention and
the National Institute of Diabetes and Digestive and Kidney Diseases. A
report on the recommendations will be published in the July issue of the
journal Diabetes Care. Doctors usually follow the association's
recommendations.
Dr. K.G.M.M. Alberti, director of the World Health Organization's
Collaborating Center for Research and Development in Laboratory
Techniques in Diabetes, said at a press conference that that organization
fully supports the association's recommendations.
The redefinition of diabetes may have a powerful impact. Researchers say
they hope that by leading to earlier detection, the guidelines will improve
treatment and prevent complications like cardiovascular disease and
blindness.
But it is not known whether those benefits will be realized, and in the
meantime, the scientists say, there are potential risks in telling a large pool
of symptom-free people they have a chronic disease with potentially
devastating consequences. Those individuals would have to deal with
employers and insurers, and in some cases make decisions about taking
potent drugs whose long-term effects are not entirely known.
According to the new guidelines, a person has diabetes if two readings,
on two different days, reach 126 milligrams per deciliter or higher on a
simple blood test called a fasting plasma glucose -- better known as
fasting blood sugar. The previous cutoff, set in 1979, was 140 or higher.
The association also decided that the fasting plasma glucose test was
sufficient to make the diagnosis, and could replace a more expensive,
time-consuming and unpleasant procedure, the oral glucose-tolerance
test, which requires that patients drink a glucose solution and then have
blood drawn two hours later. (The dipsticks used to test urine samples
for glucose in many doctor's offices are not adequate for diagnosing
diabetes.)
The association said it recommends lowering the blood-sugar cut-off to
126 because research has shown that people with readings in the low- to
mid-120s develop complications of diabetes, including blood-vessel
damage that can eventually lead to heart disease, stroke, kidney failure,
blindness, nerve damage and amputation of the feet and legs.
The American Diabetes Association estimates that each year, the disease
results in 54,000 amputations, 12,000 to 24,000 cases of blindness and
178,000 deaths from diabetes and its complications.
But in its early stages, high blood sugar produces no symptoms, and
many adults have diabetes for 7 years or more before it is diagnosed. By
that time, irreversible damage to the circulatory system and organs may
already have occurred.
"Damage is occurring earlier than we previously thought," said Dr. James
Gavin, senior scientific officer at the Howard Hughes Medical Institute in
Chevy Chase, Md. He was the chairman of a group of international
experts that developed the guidelines after analyzing 15 years of research.
"The earlier we pick up the disease and the more aggressive we are in
treating it, the greater the likelihood we'll be able to avoid these kinds of
complications," Gavin said. "This is an attempt to raise public awareness."
Although he thinks the new guidelines will ultimately benefit patients,
Gavin said he did not expect the changes to be unanimously welcomed.
He said many people fear a diagnosis of diabetes, not only because of
what it means medically but also because it may expose them to insurance
or employment discrimination. Cases of discrimination have occurred, he
said.
"But diabetes has earned those negative connotations because we've
been picking it up and trying to intervene late in its course when the
complications have had a chance to get off to a running start," he said.
"The sting is taken away if we can avoid complications."
Eight million Americans have been diagnosed with diabetes, and another
8 million are thought to have the disease without knowing it. The new
guidelines won't change the combined total, but are expected to shift 2
million people who don't know they are diabetic into the group that does
know.
Nearly all the new cases will be adult-onset or type 2 diabetes, which
affects 90 percent to 95 percent of diabetics and which tends to develop
after age 40. Type 1, which is more severe, usually develops in childhood
or adolescence and is caused by a severe deficiency of the hormone
insulin. Type 2 patients are more likely than type 1 to be overweight and
to have high blood pressure and other risk factors for heart disease.
People with type 2 diabetes have high levels of blood sugar because their
bodies cannot use insulin properly, and in some cases do not make
enough of it to metabolize glucose and control its levels in the blood. The
immediate goal of treatment is to keep blood sugar within the normal
range. Although the benefit of that strategy has not been proved for type
2 diabetics, many researchers think it must exist.
Unlike people with type 1 diabetes, who require insulin shots to control
the disease, those with type 2 don't always have to take drugs, Gavin
said. Obesity and lack of exercise are major risk factors for type 2
diabetes, and it can sometimes be controlled with weight loss, exercise
and attention to diet.
If those methods fail, or if blood sugar is very high, insulin shots or oral
medications may be needed. The American Diabetes Association
estimates that 10 percent to 20 percent of type 2 patients are treated with
diet and exercise, 30 percent to 40 percent with oral drugs, and 30
percent to 40 percent with insulin or insulin and oral medications.
Dr. Richard C. Eastman, of the National Institute of Diabetes and
Digestive and Kidney Diseases, who wrote an editorial accompanying the
report on the new guidelines in Diabetes Care, said: "Many of the people
who are newly diagnosed won't require any specific therapy because their
level of blood sugar is not very high. But it goes up with time, and they
need to be followed closely and therapy begun earlier."
A researcher who did not work on the new guidelines, Dr. David Nathan,
director of the diabetes center at the Massachusetts General Hospital and
Harvard Medical School, agreed that undiagnosed diabetes is a major
health problem because millions of Americans don't realize they have it.
"The question that remains unresolved is, by screening, do we actually do
them a favor?" Nathan said. "Will they have a better health status? It
makes sense that they should, but there have never been studies to prove
the case."
Just making the diagnosis does not guarantee patients better health care,
Nathan said. "One problem in the U.S. is that physicians are not
aggressive enough in treating type 2 diabetes," he said.
But if they were, he added, that might lead to another set of problems.
Even though high blood sugar is dangerous, and patients would almost
certainly be healthier if it could be lowered, he is concerned about the
safety of the drugs used to lower it in type 2 diabetics.
Studies have suggested that some of the drugs may contribute to heart
disease, and some are dispensed with warnings of the increased risk.
"We start with diet and exercise and rather rapidly move into a number of
drugs, without data to suggest that's good for patients over a long time,"
Nathan said. "We must be careful we don't cause some mischief, don't
make their heart disease worse."
Nonetheless, Nathan said, "On balance, I probably agree with the
recommendations. But there is a cautionary side to this story."
In addition to establishing a fasting blood sugar of 126 as the cutoff for
diabetes, the guidelines also designate normal as below 110, and identify
a danger zone of 110 to 125 in which the body's ability to process
glucose is considered to be impaired.
Gavin said people in that zone should be tested more frequently and
counseled about ways to lower their blood sugar and reduce the risk of
heart disease.
"That might include losing weight or not gaining any, increasing physical
activity, stopping smoking, and aggressively treating high blood pressure
or high blood fat," he said.
A nationwide study, still enrolling patients, is attempting to determine
whether drugs or life style changes can prevent diabetes in people in this
category, Nathan said. |
