Diabetes Prevention through Lifestyle Modification - Research Paper Example

Diabetes Prevention through Lifestyle Modification Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Name Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Course Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Lecture Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx 14th March, 2012. Abstract This research paper seeks to analyze the data that is available that show sport and/or diet can slow down progress for individuals at a risk of positive Type 2 diabetes diagnosis. This research paper seeks to further support evidence that high occurrence of Type 2 diabetes is a consequence of non-participation in physical activities and a poor diet regimen. The paper presents evidence collected from studies investigating these two lifestyle modification strategies and then proceeds to analyze the findings of various studies in relation to the reduction of diabetes prevalence through sports (exercise) and a modified diet. Contents Contents 3 Introduction Diabetes full name Diabetes Mellitus; is a persistent condition where one has blood sugar at high levels, high blood sugar is caused by lack of insulin in the body or by cells not responding to the insulin produced. Insulin is a hormonal secretion of the pancreas responsible for metabolizing carbohydrate and fats in the body (WHO 2011, pp.20). Insulin is responsible for conversion of glucose in the blood to glycogen and its eventual storage in the Liver and muscles. The most common indicators of diabetes are recurrent urination (polyuria), unquenchable thirst and feeling hungrier (polyphagia). Pan et al (1997) introduces two intermediate stages of Type 2 diabetes: ’Impaired fasting glycaemia (IFG) and impaired glucose tolerance (IGT)’ (pp 439) .The two conditions are a transitional stage to the commencement of Type 2 diabetes. People diagnosed with these two conditions normally progress to type 2 Diabetes, this progression is preventable through maintaining one’s body weight at an optimal level, taking part in at least 30 minutes of light exercise daily, reduction of sugar and saturated fat in the diet, daily servings of fruit and vegetables and avoiding tobacco (Pan et al 1997, pp 440). Pre-diabetes is where a patient has elevated blood glucose levels that are not high enough to be diagnosed as diabetes, in King and Rewers it is referred to as “impaired fasting glucose or impaired glucose tolerance” (1993, pp.157). Pre-diabetes puts one at a higher risk of developing cardiovascular diseases; overweight people above 45 years are at the greatest risk of pre-diabetes (Chan, et al 1994, pp 969). Other characteristics that indicate elevated risk of being diagnosed with diabetes are: living a sedentary life, having first-degree relatives who are diabetic, coming from a minority family background, being diagnosed with gestational diabetes, having blood pressure above 140/90 mmHg, history of cardiovascular diseases and finally having other conditions associated with insulin resistance (Colditz, et al 1990, pp.508). Diabetes can be categorized into three main types; Type 1 diabetes is a consequence of body cells not producing enough insulin, the cause of Type 1 is not known currently (WHO 2011, pp.13). Type 2 diabetes is result of wasteful use of insulin by the body; only about 89% of all diagnosed diabetes cases are Type 2 (WHO 2011, pp.13). Type 2 diabetes mostly relates to a person’s lifestyle; mostly it affects physically inactive people and those with excess body weight. According to King and Rewers (1993) diabetes Type 3 is; ‘Gestational diabetes is diagnosed first when pregnant women go for pre-natal check-up’ (pp.157). According to World Health Organization facts on Diabetes “346 million” men and women have diabetes; around 3.4 million lost their lives through Diabetes in 2004 (2011, pp.3). WHO estimates that Deaths caused by Diabetes will increase by more than 100% by the year 2030(pp.4).The organization recommends a good diet, regular exercise and avoidance of smoking to reduce chances of being diagnosed with Type 2 Diabetes (WHO 2011, pp.5). Diabetes can develop complications that include damaged heart and blood vessels, deteriorated eyesight, kidneys and nerves. These complications manifest themselves as: Increased risk of heart conditions and stroke, WHO statistics show that 50% percent of diabetes deaths are caused by heart disease, stroke or other cardiovascular diseases (WHO 2011, pp.5). Diabetes lowers blood flow to the feet increasing the risk of getting septic wounds in the feet and eventual amputation (King, Auber & Herman1998, pp.1414-1431). Inflammation to the eyes caused by diabetes is a major cause of blindness, occurring due to years of minute damage of tiny blood capillaries in the eye’s retina. Around 2 % of those diagnosed with diabetes for more than15 years becomes blind, while 10% develop severe visual impairment. Kidney failure accounts for between 10-20 per cent of deaths by diabetes (Pan et al1997, pp 358). Diabetes neuropathy a diabetes complication caused by nerve damage affects 10 per cent of people with diabetes. People with Type 2 diabetes have a greater risk of dying in comparison to ordinary people; twice more likely to die than ordinary people. Looking at the facts in the above introduction, Type 2 Diabetes as a medical condition has to be taken seriously by governments, individuals and health care providers. Preventive measures need to be emphasized on as regard Type 2 diabetes and control measures for Type 1 diabetes. Regular exercise and a good diet are the two major intervention methods adopted by most government and healthcare providers to prevent and/or delay the commencement of Type 2 diabetes and control Type 1 diabetes (Pan et al1997, pp 442). This paper seeks to explore the effectiveness of using the two methods to prevent and control Type 2 diabetes; the more common and preventable. Methodology This research paper adopted the literature review method of collecting information previously available through various studies conducted to investigate how various factors including sport and dieting relate to the prevention/delaying of Type 2 diabetes. The Literature review method is going to be adopted as it takes advantage of the availability various academic works that tackle the use of lifestyle intervention as a means of preventing Type 2 diabetes. Other methodologies would not be appropriate in the production of this paper as they would be too expensive and need a lot of time to undertake. Discussion and Analyses of Diabetes Studies In order to effectively analyze the impacts of sporting activities and diet modification on prevention/delay of Type 2 diabetes studies select participants with high or moderate risk of contracting diabetes to enable easier analysis of the progression rate to diabetes. The Malmo feasibility study selected 181 males from Malmo area who had participated in an earlier trial and had pre-diabetes (IGT). The Finnish Diabetes prevention study acronym DPS involved another group also at a very high risk of eventually being diagnosed with diabetes. Tuomilehto et al (2001 pp.256) list the Characteristics of participants of the DPS study as follows: “they had first-degree relatives who had been diagnosed with diabetes, their ages ranged between 40 to 65 years old, their Body Mass Index (BMI) was above 25 additionally a positive diagnosis of impaired glucose tolerance was also necessary for inclusion”. A similar study conducted in the U. S. A called the Diabetes prevention program abbreviated DPP as well involved a study of individuals diagnosed with impaired glucose tolerance. The prevention program selected participants that were overweight and had average blood glucose levels above normal levels (Tuomilehto et al 2001 pp.256). According to DPPRG (2002a, pp 394) the DPP had a total of 3,224 participants, 45 per cent were drawn from minorities known to be at an elevated risk of contracting Diabetes Type 2. The DPPRG (2002a, pp 394) identifies the most common characteristic found on participants chosen for DPP study as “a positive diagnosis of IGT (impaired glucose tolerance)” is indicted by high blood glucose (sugar) levels that are not sufficient to be diagnosed as diabetes (DPPRG 2002a, pp 394). The minority groups identified for participation in this study include Alaskan natives, African American, American Indians, American Asians, Hispanic/Latino or Pacific Islanders (DPPRG 2002a, pp 394). The Da Qing study (a large population based screening program) in china in 1986, Selected 577 participants already diagnosed with impaired fasting glucose. Compared to DPS and DPP study the subjects of the Da Qing study were leaner with an average BMI of 25.8 kg/m2 at baseline (Tuomilehto, Lindstrom & Qiao 2005, pp. 567). Each of these studies did not select individuals with normal glucose tolerance; instead all participants selected were recognized to be on the path of progressing to diabetes. Study Designs Adopted in Diabetes Prevention Studies In order to enhance the outcomes of any investigation into the impacts of modifying diet and physical activity on the prevention/delay of Type 2 diabetes any study into this subject has to be carefully designed. Previous studies were designed to coach participant on how they could modify their lifestyle in order to influence outcomes related to prevention of diabetes. Certain exercise and diet targets were set for each participant, depending on which group of the study the participant belonged to, however each study had targets that differed from the other studies. The Da Qing study had the most moderate intervention targets with participants at baseline with a BMI of 25 kg/m2 aiming for a reduction of 1 kg/m2 , the reference group were to take a high carbohydrate diet of between 55 per cent and 65 per cent combined with a moderate fat diet(Pan et al1997, pp 438). The Finnish Diabetes prevention assigned participants either to the intervention group based on centre, sex and the mean plasma glucose ratio. The reference group was given non-specific advice on nutrition and exercising; they were not encouraged to take up either. According to Eriksson-Lindström (et al 1999, pp. 794) the group subjected to intervention was set specific targets detailing how they would achieve their dietary and exercise goals, the goals were lose more than 5 per cent of their total weight, reduce their fat/ saturated fat ingestion to a range of 30 per cent and 10% respectively, Increase dietary fiber to more than 15 g/1,000kcal and exercising for more than half an hour daily. The diet regimen involved the regular ingestion of unprocessed products, fruits, low-fat milk, vegetables, beef products, softer margarines, and oils enrichened with Monosaturated fatty acids (Eriksson-Lindström & Lindgarde 1991, pp. 891). To increase their activity levels participants were supposed to take endurance activities including swimming, jogging, and ball games and skiing (Eriksson-Lindström & Lindgarde 1991, pp. 891). At the beginning of the study each patient was required to fill in a medical history questionnaire and in later annual visits the same process was repeated. The participants of the DPS were monitored annually; the yearly visit consisted of a physical check-up where anthropometric and blood pressure was taken and an oral glucose tolerance test administered (Eriksson-Lindström et al 1999, pp. 795). Plasma glucose was measured using a standard linear-regression equation developed by the staff of Helsinki Central laboratory. Diabetes is defined by WHO as either fasting plasma glucose concentrate equal/ higher than140 mg/deciliter or plasma glucose concentrate of higher than or equal/higher than 200 mg/deciliter after 120 minutes of an orally taken glucose challenge (Lanne-Parikka et al. 2008). These measurements of glucose concentration were compared against these levels that are indicators of a diagnosis of Type 2 diabetes. Once a subject was diagnosed as non-diabetic by a second test they continued with the original program assignment. On each annual visit the staff employed by the DPS would take a medical examination of the DPS participants in a number of areas: “antropometric measurements, blood pressure, uric acid, GAD-antibodies, electrocardiogram, 2 Km walk test, 3 d food record, Health status, RAND 36-item health survey, human leucocyte antigens, other genetic factors, Liver function, serum lipids, PAI-1, fibrinogen, thyroid stimulating hormone, 24 h exercise diary plus 12 month exercise questionnaire” (Uusitupa et al 2000, pp.2) The DPP adopted a multicenter approach consisting of participants drawn from 27 clinical centers spread across the United States of America. The study groups were divided into three: lifestyle intervention cluster, the metformin cluster and a Placebo cluster (DPPRG 2002b, pp.400) The lifestyle intervention group was taken through a 16 week curriculum, where they were taught how to properly diet and how to improve their physical activeness to a modest level (DPPRG 2002a, pp 395). The group was supposed to record a 7% drop of their body mass by keeping their calorie count low and exercising for an average of 150 minutes per week. The metformin study group took 850 mg metformin tablet 2 times a day (DPPRG 2002a, pp 393). A control group was given Placebo pills, while a forth part of the study group later discontinued were put on troglitazone (later found to cause serious liver damage). Evidence from Previous studies The intervention and reference group of the DPS (Finnish Diabetes prevention study) initially had almost similar baseline characteristics indicating an increased risk of a diabetes diagnosis (Eriksson-Lindström et al 1999, pp. 794). More than 50% of both groups recorded a BMI of more than 30 kg/m2, also they exercised for less than 160 minutes every week. They also spent a high percentage of their time either reading or watching television (Eriksson-Lindström et al 1999, pp. 796). All participant baseline diet was also very identical; however the control group’s energy portion of saturated fat was a little above that of the intervention group. When the first annual visit was made the number of sedentary individuals was found to have dropped to 14 per cent in the intervention group and 30 per cent in the control group (Eriksson-Lindström & Lindgarde 1991, pp. 891). By the third year proportion of sedentary participants inside the intervention group had risen to 17% while among the control group it had fallen to 29%. Findings at the third year of study revealed a larger decrease in the intake of fat (Saturated and Monosaturated) among the intervention group, Cholesterol intake, absolute fat amount and energy intake was also lower in the intervention group (Eriksson-Lindström & Lindgarde 1991, pp. 890). Only 14% of the control group participants were able to achieve more than the 5 per cent weight loss targeted by the study in the first year. According to DPPRG 2002 the group subjected to interventions “lost 4.4±5.1 kg in the first year and 3.5±5.5 kg after the second year, while their reference group lost 0.8±4.4 kg after the first year and 0.8±4.4 kg after the second year” (pp. 2165–2166) The blood and IFG levels dropped in the intervention group, but among the controls they rose significantly. Among the control group 59 new incidences of diabetes Type 2 were diagnosed while among the control group only 27 new cases were found (Eriksson-Lindström & Lindgarde 1991, pp. 890). According to the Diabetes Prevention Program Research Group (DPPRG) the Diabetes prevention program (DPP) study was aimed at comparing the impacts of lifestyle intervention (modified diet and being more physical active) with the effects of oral metformin medication (Glucophage) in preventing/delaying the commencement of diabetes (pp. 2165–2166). The DPP based on random sample population could be said to have been more objective than the Finnish trials. After almost 3 years follow up the test group achieved a 58 per cent drop in diabetes diagnosis rate in comparison to the reference group (DPPRG 2002a, pp 395). The group had achieved a average weight drop of 7% and with more than 75% of the test group had realizing the exercise target within 6 months of initiation of the study (DPPRG 1999). Weight loss was found to be the most significant intervention factor with each kilogram lost calculated to have reduced Diabetes incidence rate by 16%. However those unable to reach more than 7 per cent baseline weight loss target, still recorded a 14 per cent lesser incidence rate compared to the reference group (DPPRG 2002a, pp 395). The Intervention measures were found to be equally effective for all, racial and ethnic groupings in the test group (Manson. et al 1991, pp.772). The DPP study found out that those above 60 years achieved higher reduction in diabetes incidence. This reduction rate was owed to their greater percentage increase in physical activity and consequently higher percentage weight reduction (DPPRG 2006) Participants on oral metformin medication were found to have reduced their risk of diabetes to record a 31 per cent diabetes incidence. Metformin was found to be equally effective on both genders, but its effects were less pronounced on participants who were more than 45 years old. Those who benefited most from metformin intervention were between the ages of 25 to 44 and had a BMI (body mass index) above 35; they were initially more than 60 pounds overweight. Only 7.8 per cent of the metformin group progressed to diabetes compared to 11 per cent in the control group. Durable Impacts of Modified Lifestyle on prevention of diabetes The Malmo feasibility study after a 12-year study period revealed that a small period of lifestyle intervention could have long lasting benefits for patients with pre-diabetes (Eriksson-Lindström & Lindgarde 1998 pp. 1010-1016). The initial study involved comparison of 161 men where exercise and diet interventions were applied and a second control group of 56 men who declined to join the exercising and dieting program (Ohlson, et al 1990, pp.107). In the initial 5 year study period the intervention group recorded a decreased diabetes incidence at 11% while the reference group recorded a 29 per cent diabetes incidence rate. The all mortality rate after a 12-year study period was found to be differing significantly with the intervention group recording a 6.5 per cent per 1,000 person-years mortality rate, in contrast with a 14% per 1,000 person-years in the reference group. Mortality rates among the intervention group were found to be the same with that of normal men (Chan, et al 1994, pp 968). At the end of the Malmo feasibility study more than 50% of former subjects of the intervention group recorded normalized glucose tolerance. The occurrence of diabetes was found to have decreased ranging between 4.3 % per year to 1.3 % (Ohlson, et al 1990, pp.107) among the lifestyle intervention group in comparison to the reference group. A 10 year follow-up to the DPP has shown diabetes incidence rate to be higher in the follow-up period than those recorded during the DPP period. However, the three different groups recorded different diabetes incidence rates, the lifestyle intervention group recorded between 24 and 42 per cent reduction rate while those who continued metformin treatment recorded between 7 and 8 % reduction in comparison with the reference group. Conclusion and Future Recommendations The Finnish Diabetes prevention program developed a scoring system that evaluated how an individual had been able to relatively attain the programs targets in relation with the individual’s baseline characteristics; the individuals achieving most target scored 5, while those who achieved none scored 0. A closer inspection of the success scores and the diabetes incidence rate reveals that the higher the success score in achieving the program’s target interventions the lower the diabetes incidence (Eriksson-Lindström & Lindgarde 1991, pp. 891). The figure table and graph below illustrates this strong inverse correlation. Comparison of Diabetes Incidence against success scores During the Finnish Diabetes prevention program Success score 0 1 2 3 4 5 Diabetes Incidence among the Control group 31% 25% 30% 12% 0% 0% Diabetes Incidence among the Intervention group 38% 15% 12% 5% 0% 0% Source: http://eurheartjsupp.oxfordjournals.org/content/7/suppl_D/D18.full.pdf The DPS was very successful and 47 individuals who had attained at least four out of the five intervention targets in the DPS intervention group did not progress to diabetes. However, the trials were criticized as they were seen to lack objectivity as they presented an overly simplistic and optimistic outlook (Lanne-Parikka et al. 2008). This criticism stems from the fact that the sample population consisted of volunteers who would be over-enthusiastic in implementing the trials target (Lindström et al 2006, pp.765). But still this study demonstrates that a good exercise and diet regimen can delay/prevent the occurrence of diabetes in elevated risk individuals, this conclusion is supported by the fact that the trials targets were very modest and achievable by ordinary people. The DPP trials were found to have been the most cost effective measured against quality-adjusted life year, in comparison to the reference group. Intensive Lifestyle (ILS) intervention cost more than $1,000 compared to $31,000 for metformin tablet intervention (DPPRG 2002b, pp.401) .ILS was found to be the most effective and cost efficient of preventing the occurence of diabetes. However, the DPP trials were criticized in some quarters as being too expensive to be applied on the general population. The Diabetes Prevention Trials were an indication that moderate weight loss through increased exercise and a low calorie and fat diet can really delay/prevent the occurrence of Type 2 diabetes (DPPRG 2002a, pp.400). These two interventions take down the risk of diabetes by improving the individuals’ ability to metabolize glucose and/or produce insulin. Recent studies suggest a combination of lifestyle modification and metformin medication can further delay/prevent the commencement of Type 2 diabetes. Even though the DPP and the FDPS trials unearthed new knowledge about Type 2 diabetes prevention, they only demonstrated the short-time effect of lifestyle modification on prevention of diabetes (King, Aubert & Herman 1998, pp 1425). Follow-up studies of the Malmo feasibility study and the DPP were used to illustrate the lasting impacts of exercising and diet modification on delaying and preventing Type 2 diabetes (Eriksson-Lindström & Lindgarde 1991). The Malmo study after a 6-year follow-up period recorded an average cumulative diabetes incidence of 43% for the intervention cluster contrasting with a 68 per cent incidence rate among the reference cluster. In a 20-year post intervention follow-up published in 2008 risk reduction was found to have remained constant (Pan et al1997, pp 439). However, Diabetes incidence rate was very high among the intervention and the control group and eventually 80 and 93% eventually progressing to diabetes. A ten year follow up study of the DPP also shows significant evidence that exercising and good diet have a long lasting impact that delay/prevent the occurrence of Type 2 diabetes. People who were formerly in the DPP’s lifestyle intervention group were found to have relatively lower cumulative diabetes incidence rate than those in either the metformin or reference group. From evidence shown in the above studies it is clear Type 2 (non-Insulin Dependent Diabetes) can be avoided or its commencement delayed. Intensive life style interventions were found to have beneficial short-term and long-term effects in delaying and preventing the incidence of Type 2 diabetes. Most of these interventions are low cost and implementable even in the health systems of the poorest countries in the world. Even at home high risk individuals can adopt a routine that can prevent them from eventually becoming diabetic. Such a routine should be aimed at achieving a weight loss of between 5-10%, exercise too of at least 30 minutes per day was found to significantly lower the risk of one progressing from pre-diabetes to a full diabetes diagnosis. However these studies were conducted in a controlled environment and the applicability of their findings in daily life is a matter of concern for healthcare providers. The studies above involved high-risk individuals working with nurses and doctors motivated by financial incentives offered by the study and their own enthusiasm in participating in the studies. In an ordinary setting these conditions are very hard to replicate and any nation that is able to apply these findings will make a huge step in the war against Type 2 diabetes. Diabetes places a great financial burden on many governments and households worldwide, but the reality is that Diabetes Type 2 is preventable using these relatively cheap methods. All future efforts to combat diabetes should adopt these two proven strategies (exercise and good diet) to be able to win the war against diabetes. Bibliographies Chan, J.M., Rimm, E.B. Colditz, G.A, Stampfer, M.J. & Willett, W.C. 1994. 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