The Diabetes Epidemic Is Like a Tsunami Hitting in Waves

Cardiometabolic health highlighted at ADA 2012
August 2012, Vol 5, No 5, Special Issue ADA 2012 Highlights
Wayne Kuznar

Philadelphia, PA—The epidemic of diabetes is like a tsunami that will strike in waves, said Geralyn R. Spollett, MSN, ANP-CS, CDE, President of Health Care & Education, American Diabetes Association (ADA), Alex­andria, VA, and Associate Director of the Yale Diabetes Center, Yale School of Medicine, New Haven, CT, at the 2012 ADA annual meeting. The result will be 380 million people worldwide in 2025 with diagnosed diabetes, with 53.1 million of them from the United States.

Tsunamis generally consist of a series of waves that arrive in a so-called wave train, Ms Spollett said.

The Obesity Wave
The first wave in the diabetes epidemic is an increasing incidence of obesity. Worldwide, 2.8 million people die annually as a result of being overweight or obese. Between 1980 and 2008, the worldwide prevalence of obesity nearly doubled, Ms Spollett noted.

As with a natural tsunami, expect significant financial distress and destruction with the surge in diabetes, Ms Spollett pointed out. The impact of diabetes will be felt at the state and federal levels in the form of higher healthcare costs, and, as the costs for insurance increase, it will be felt at the small business level as well.

Diabetes will also place an increased burden on the primary care health system and will diminish the availability of specialty services. The most dire of these predictions asserts that annual medical and societal costs will increase by 72%, to a total of $514 billion.

The Hyperglycemic Wave
The second wave of the diabetes tsunami is the alarming increase in the rate of hyperglycemia.

A 3-Step Process to Survive a Tsunami
Surviving a tsunami is a 3-step process. The first step is to warn the public by sounding an alarm. Diabetes educators must “heighten our nation’s sense of urgency for the growing diabetes epidemic,” Ms Spollett said, by convincing the public that it must take diabetes very seriously, because the disease is potentially deadly. Diabetes kills more Americans annually than breast cancer and AIDS combined, she said.

The second step in survival is for clinicians and educators to help reduce the impact of diabetes by promoting increased allocation of resources for research into the pre­vention, care, and cure of diabetes.

The third step in surviving a tsunami is “taking” to higher ground. “Major change is usually driven from the bottom up, by an informed and assertive public,” she explained.

“My dream is that in understanding and responding to the crisis of diabetes, a national diabetes prevention plan will be seen as important, with the help of all of our citizens, and that the work we have done becomes a beacon for the broader future of healthcare,” said Ms Spollett.

A national diabetes prevention plan would include building community awareness of diabetes, improving nutrition from farm to table, and fostering activities to prevent an increase in diabetes (ie, supporting physical education, bike paths/exercise courses, and public transportation), Ms Spollett said, and would offer financial reimbursement for counseling and education for those at risk.

ADA’s Response to Hurricane Katrina
In a separate address, Vivian Fonseca, MD, ADA’s President of Medicine & Science and Chief of the Section of Endocrinology at Tulane University School of Medicine, New Orleans, LA, noted that the ADA was unprepared for the devastation that Hurricane Katrina brought to New Orleans and to the surrounding Gulf Coast in 2005.

“There were no physicians, no nurses, and no pharmacists available after the hurricane,” said Dr Fonseca. “This had an immediate effect on the lives of people with diabetes.”

Interruptions of care meant that hemoglobin (Hb) A1c levels went uncontrolled, and the interruptions affected those with private insurance as well as those with public coverage or no insurance. Some of the uninsured went without diabetes care for as long as 2 years.

Most healthcare facilities in New Orleans, including research facilities, were destroyed by Hurricane Katrina. The ADA responded with emergency grants to locate patients who had to abandon the city after the storm, said Dr Fonseca.

The ADA also created a task force that developed first responders’ best practices, which include diabetes care. Disaster preparedness is now part of the ADA’s standard of care.

A strategic plan by the ADA demands new research priorities and transformational approaches to treatment. A new series of grants shifts the focus away from specific compounds to individual investigators, in the hopes of encouraging more risk taking in research, he said.

Discovery of a Third Type of Adipose Tissue

After Dr Fonseca’s address, Bruce Spiegelman, PhD, Professor of Cell Biology, Harvard Medical School, Boston, chronicled the discovery of irisin, a key regulatory hormone in glucose metabolism, and beige fat cells, a third type of adipose tissue in addition to brown fat and white fat.

Beige fat, which can burn off calories unlike white fat, is genetically distinct from brown fat, which is found in small mammals and human infants, affording them protection from the cold. High levels of the adipose tissue regulator PRDM 16 (PR domain containing 16) can turn white fat into beige fat. Genetically manipulated mice that create more brown or beige fat have increased glucose tolerance and antiobesity actions, explained Dr Spiegelman.

“Beige fat can improve the metabolic health of an animal,” he said. “In human beings, this same browning is linked with exercise.”

Exercise induces an improvement in glucose metabolism. Recent studies show that peroxisome proliferator-activated receptor g coactivator-1aα (PGC-1a), a regulator of mitochon­drial biogenesis that is upregulated by vigorous exercise, plays an important role in converting white fat into brown fat. In tissue culture, PGC-1aα stimulates glucose uptake and angiogenesis, thus mimicking the beneficial effects of exercise.

Exercise is thought to produce the secretion of irisin, a molecule that increases the amount of beige fat. In obese humans, the expression of circulating levels of irisin increases by 40% to 60% after 4 weeks of exercise training.

“Irisin causes a browning reaction to protect against metabolic disease,” said Dr Spiegelman. Although irisin is a molecule at the proof-of-concept stage that is not appropriate for use in human beings, the hope is that an understanding of its actions can lead to the de­velopment of a new generation of therapeutics, he noted.

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