Answer: Optimal normalization of glucose levels in diabetes patients has been shown to lower the long term risks of diabetic complications (such as diabetic eye, kidney, blood vessel and nerve diseases). Normal fasting morning blood glucose level is 70-120 mg/dl. Therefore, am fasting blood glucose level of 130mg/dl is acceptable. However, having satisfactory am blood glucose level is not enough. Ideally, blood glucose levels before lunch, before dinner, and at bedtime should also be well controlled. Oftentimes, doctor will order a blood test for HgA1C test. Normal HgA1C level indicates good glucose control, while abnormally high level indicates inadequate glucose control.

The risk of medication treatment of high blood glucose is overshooting, causing hypoglycemia (low blood glucose). Symptoms of hypoglycemia include sweating, palpitations, tremor, and weakness. Severe, prolonged hypoglycemia is dangerous and can lead to syncope and other problems. In patients who do not experience early warning symptoms of hypoglycemia, and in patients with coronary heart disease or who have seizures with hypoglycemia, doctors will settle for less ideal control of blood glucose to avoid problems of hypoglycemia.

Oh, boy, more people telling me to lose weight and get up off the couch. What’s the big deal this time?

This study is one of the best demonstrations that a few simple changes in lifestyle can have a powerful impact on preventing disease in high-risk people. In this research, people on the brink of developing diabetes followed a lower-fat diet, walked or did some other form of moderate exercise about 30 minutes a day five days a week and lost around 10 to 15 pounds. These changes reduced their chances of getting type 2 diabetes by almost 60 percent. Even better, this program worked in men and women, in young adults and seniors, and in all races. And the lifestyle changes were nearly twice as effective as the expensive medication to which it was compared.

Hey, wait, I know statistics can exaggerate the importance of a study. What were the chances of these people getting diabetes without any treatment? What were their chances if they made the changes?

Wow, you’re good. Each year, 10 percent of the people in this study who got no treatment developed diabetes. Do the math over a period of years and you can see this group is at very high risk indeed. About 5 percent of those who followed the moderate diet and exercise program developed the disease each year. That’s an impressive drop in risk — but it’s not a perfect record. The lifestyle program does not appear to prevent the disease in everybody who is at risk, but it improves their odds significantly.

Why are we so worried about diabetes all of a sudden? I thought heart disease and high blood pressure were the real killers.

Type 2 diabetes has reached epidemic proportions, and the number of people at risk for developing it increases every year. Some 16 million people have the disease and an estimated 800,000 Americans will be diagnosed this year. Type 2 diabetes is a chronic degenerative disease characterized by elevated blood sugar levels; it’s the leading cause of kidney disease, limb amputations and acquired blindness in adults. It also increases the risk of heart disease and stroke. (Many deaths blamed on heart attack and stroke are associated with diabetes.) Rates of type 2 diabetes have tripled in the last 30 years because of the rise in obesity and sedentary living. Worse, type 2 diabetes is being diagnosed in people at increasingly younger ages — even in kids. So diabetes is one of the most pervasive and deadly results of the American lifestyle.

How do I know if I’m enough like the people in this study to benefit from the lifestyle changes?

Most people in this study were overweight and sedentary adults. To be eligible, they also had to have “impaired glucose tolerance” — a pre-diabetic condition in which the body fails to process glucose efficiently, elevating blood sugar levels. (Over time, high blood sugar damages organs and blood vessels throughout the body, leading to kidney failure, blindness, amputations and heart disease.) An estimated 10 million Americans have this pre-diabetic condition, and most have lifestyles that put them at risk for developing it. Strictly speaking, the benefits demonstrated in the study apply only to those who already have impaired glucose intolerance — but researchers believe that similar interventions can reduce risk for others.

How do I know if I’m “overweight”?

If your friends won’t tell you, we will. You can start with body mass index — a figure that considers height and weight. If you have a BMI of 30 or above — technically the cutoff for “obesity” — you’re in the diabetes danger zone. At 5 feet 10 inches tall, that’s 209 pounds; at 5-4, it’s 174 pounds. (To compute your BMI on the Web, go to www.nhlbisupport.com/bmi/ You’ll also find a link there to a BMI chart.)

A BMI above 25 (128 for a five-footer, 164 for someone 5-8, 184 for a six-footer) is considered “overweight” and is also associated with an increased risk for impaired glucose tolerance.

Every time you guys write about the body mass index, people write in and say it’s inaccurate, deeming even those who have muscular physiques “fat.”

If you have a muscular physique and low body fat like the professional athletes cited by those letter writers, chances are you’re not at risk for diabetes. We’ll be politic and say that if your BMI is 30 or over, chances are pretty good that you are at increased risk. If you prefer, measure your body fat instead — but it’s hard to do accurately without professional help. Healthy ranges vary by age and sex, but if you’re a woman with a body fat number above 35 percent or a man whose number is over 24 percent, you should be worried. (Log on to www.shapeup.org/bodylab/ frmst.htm for more information on body fat.)

Are there other things aside from body mass or body fat that put me in a high-risk group?

Having a family member with diabetes adds to your risk. African Americans, Hispanics and Native Americans also face much higher risk of diabetes. So do women who developed gestational diabetes while pregnant, about half of whom develop full-blown diabetes later in life. People in these groups may want to consider preventive lifestyle changes even if their BMIs are not near 30.

How can I find out if my glucose tolerance is impaired?

Ask your doctor for a fasting glucose tolerance blood test. You’ll have to go without food for 10 hours before the test. At the doctor’s office, you drink a sugary liquid and then have your blood drawn at regular intervals over the next two hours to see how your body metabolizes the sugar.

Sounds like fun. How much is this going to cost me?

It’s a bargain: about $15 to $35. It’s often covered by health insurance. It’s also the only way to definitively tell whether you are moving toward diabetes — or perhaps already have it.

What happens if I have an abnormal result?

Depends on how abnormal. If your fasting blood sugar — that’s the first sample they take — is between 95 and 125 milligrams, you have impaired glucose tolerance and are a candidate for treatment. The same goes for a two-hour blood sugar level — that’s the last one drawn in the test — of 140 to 199 milligrams. Treatment could be lifestyle changes or a prescription for metformin (Glucophage), a drug that is approved to treat diabetes.

If your fasting blood sugar is 126 milligrams or above, or if your two-hour blood sugar level is 200 milligrams or above — sorry, but you already have diabetes. You’ll need to consult your doctor for immediate treatment.

So what were these lifestyle changes, anyway?

Participants ate between 1,200 and 1,800 calories per day, with about 25 percent of total calories coming from fat — not a huge reduction below the 30 percent-from-fat maximum recommended by many health authorities, and not as strict as many low-fat weight loss diets. They also learned how to exercise daily. Most walked for 30 minutes a day at least five times a week. Those unable to walk because of arthritis — or disinclined to do so — did other activities including swimming, tennis and jogging that equaled the number of calories burned by walking.

I’ve tried these diets and programs a thousand times, but I always fail. How did the study manage to keep people with the program?

Participants got a lot of hand-holding and group support. While this aspect of the study has gotten little attention, it’s very important. Many people need help to sustain lifestyle changes.

The people in this study received intensive, one-on-one weekly diet counseling for nearly six months. They got personal coaching for workouts and attended small groups that taught low-fat cooking and emphasized healthful grocery shopping. They kept daily records of their diet and exercise.

You could duplicate the program a number of ways, some of them free, some costly. You can take a low-fat cooking class, join a walking group or gym, form a network of support, check out local hospitals or your insurance group for support services or hire a personal trainer or dietitian.

When lifestyle changes fail, it’s often because the pressures that trigger the condition in the first place — the constant rushing that leads to fast-food meals, the stress and exhaustion that leads to evenings in front of the TV, the lack of exercise in most daily activity patterns — undermine the best intentions to change. So creating a structured environment, ideally involving other people attempting the same changes, may be very useful. Enlisting the family may help, too.

If I can’t make the lifestyle changes, can’t I take a pill?

Maybe. If you don’t think you can make diet and exercise changes, taking metformin may be the choice for you — provided you don’t have liver or kidney disease or suffer from congestive heart failure. Therapy with Glucophage, the brand name for metformin, costs between $2 and $4 per day, but generic metformin is expected to hit the market in the fall, bringing prices way down.

Yes, participants in the study who took Glucophage lost a few pounds and reduced reduced their risk of diabetes significantly, although not nearly as much as the lifestyle group. But if you continue to live a sedentary life, take in more calories than you burn off, eat a high-fat diet with few fruits, vegetables and whole grains, experts believe that you won’t be as effective at lowering your risk of diabetes, heart disease, high blood pressure, arthritis, stroke and other equally entertaining conditions. It’s your choice. Really.

Answer. A lot is happening in the quest for better methods of treatment or prevention of insulin-dependent diabetes mellitus. Also called Type I diabetes, IDDM used to be called juvenile diabetes because it usually struck children. Type I diabetes is usually more serious and difficult to treat than the more common Type II diabetes (also called adult-onset diabetes), which accounts for about 90 percent of diabetes cases.

A common misconception is that all people who take insulin for treatment have insulin-dependent diabetes. Not so. IDDM refers to diabetes that requires insulin to sustain life. However, many people with non-insulin-dependent diabetes use insulin, although they don’t require it to live.

Three tracks of research are looking for answers to the problem of juvenile diabetes: 1) an immunization against Type I diabetes, 2) drugs to hinder the development of Type I diabetes and 3) pancreas transplants.

Some research points to a viral infection as the cause. If a vaccine could be developed to prevent such an infection from triggering juvenile diabetes, then many cases might be prevented. Currently, scientists aren’t sure whether the virus theory is correct or whether one or several viruses might be a culprit.

Other evidence places the blame on problems in the immune system, making it go awry and attack the cells of the pancreas, the abdominal gland that makes insulin. Drugs that suppress the immune system have been used to curb the development of juvenile diabetes in its early stages. Cyclosporine-more commonly used to prevent people from rejecting organ transplants-appears the most promising.

There are two major drawbacks to cyclosporine therapy. One is its potentially toxic side effects, particularly kidney damage. Another is the fact that the drug only postpones the development of diabetes, without eliminating it entirely. Once the drug is stopped, the diabetes reappears. Scientists are now studying the use of cyclosporine with other drugs in an attempt to reduce side effects and improve its effectiveness.

A third approach is the pancreas transplant. This technique involves giving someone with diabetes the part of the pancreas that makes insulin-the islet cells. However, there are many technical problems, with fewer than one in three transplants being successful. Improvements in technology may make this a better choice in the future.

For further information about diabetes, including programs for children with the disorder, contact the Juvenile Diabetes Foundation, 7307 MacArthur Blvd., Bethesda, Md. 20816; 320-3343, or the Washington, D.C. area affiliate of the American Diabetes Association, 1819 H St. NW, Suite No. 1200, Washington, D.C. 20006; 331-8303.

PAST STUDIES have shown that type 2 diabetes raises a person’s risk of dying from heart disease by two to three times.

THIS STUDY compared 160 people with type 2 diabetes who were randomly assigned to receive either conventional treatment for diabetes through a general practitioner or intensive treatment for eight years. The intensive treatment, which was supervised by dietitians, included lowering saturated fat intake, increasing physical activity, quitting smoking, taking drugs to lower blood pressure, cholesterol and glucose levels and using multivitamins and aspirin.

At the end of the study, those who received intensive therapy — a large majority of whom had managed to cut their blood pressure, cholesterol and glucose levels — had about half the risk of cardiac events as those who received conventional therapy.

WHO MAY BE AFFECTED BY THESE FINDINGS? People with type 2 diabetes.

CAVEATS The researchers had received funds from manufacturers of the drugs used in this study. Also, more than half the people in the conventional-therapy group were referred to diabetes specialists during the study.

BOTTOM LINE Many diabetics may be able to reduce their risk of heart disease through intensive, supervised therapy. They may wish to consult their physician about making lifestyle changes and taking drugs to control blood pressure, glucose and cholesterol.

FIND THIS STUDY Jan. 30 issue of the New England Journal of Medicine; abstract online at www.nejm.org.

A: About 90 percent of people with diabetes have Type II, also known as non-insulin dependent diabetes. Unlike those with Type I diabetes, people with Type II don’t require insulin in order to survive. For treatment, people with Type II may rely on diet and exercise alone, or use pills and insulin injections, or both.

The American Diabetes Association (ADA) has set guidelines for controlling your blood sugar, also called blood glucose. The fasting blood glucose is your level in the morning before eating or drinking anything. For this test, you should not have consumed anything after midnight. Your doctor checks your fasting glucose to see how good your control is overnight. Measuring your glucose around bedtime is important to help you avoid any episodes of dangerously low blood sugar levels while you’re asleep.

The glycated hemoglobin, also called glycosylated hemoglobin or hemoglobin A-1c, is a rough measure of your average blood sugar level during the past two to three months. Hemoglobin is the molecule in your blood cells that carries oxygen to tissues. In the presence of high levels of glucose, one type of hemoglobin, known as A-1c, irreversibly binds with glucose. This process is called glycation. The higher your blood glucose levels, the more glycated hemoglobin you have.

Your doctor can use this test to get a good idea of how well your blood glucose has been over time. Measuring your glycated hemoglobin can be especially helpful if you don’t check your blood glucose regularly. In some cases, an occasional blood glucose test may be quite high, but not be representative of your typical blood glucose. In those situations, a normal hemoglobin A-1c can reassure you that things aren’t as bad as you might have thought. On the other hand, a high hemoglobin A-1c should motivate you to do better at controlling your blood glucose.

You can also measure your blood sugar after eating, a test known as a post-prandial glucose. Doctors check this to see whether your body and your medicine can keep your blood sugar close to normal after a meal. In the table, the numbers in the left column are the upper limits of what’s considered normal. The numbers in the middle column are the targets for closely controlling your blood glucose. In the right column, action is suggested for numbers that are either too high (in which case you need more treatment) or too low (in which case you need to ease up on treatment). If your tests are consistently high, your doctor will probably change your treatment, either by increasing your medicine or adding a new medicine to your current one. In all cases, exercise, along with a low-fat, low-calorie, high-fiber diet will help improve your control. In fact, for many people with Type II diabetes, strict diet and exercise can keep your blood glucose under control without medication.

Recent research in people with Type I (insulin-dependent) diabetes suggests that carefully controlling your blood glucose lowers your risk of future complications, such as eye, kidney and nerve problems. For this reason, some doctors believe that “tight control” — keeping your blood sugar as close to normal as possible — is the best strategy for all types of diabetes. Other doctors are uncertain whether tight control is as crucial for people with Type II diabetes.

Another concern is that tight control comes at a certain cost, including a higher risk of low blood sugar reactions, and the inconvenience of the intensive monitoring and treatment. Also, it can be hard for some people to attain normal blood glucose levels even with good treatment.

Tight control and intensive monitoring aren’t for everyone, especially the elderly.

For more information, contact the local chapter of the American Diabetes Association, 1211 Connecticut Ave. NW, Suite 501, Washington, DC 20036 (telephone number: 202-331-8303) or the national office at 1660 Duke St., Alexandria, VA 22314 (phone: 800-232-3472 or 703-549-1500).

The ADA has just published the “American Diabetes Association Complete Guide to Diabetes”.

According to our study, it’s only really painful in a minority of patients — about 20% to 30%. For about the same number, the injection is actually less painful. So it can go either way.

2. How serious can the swelling become in extreme cases of lipohypertrophy?

We’ve observed some extreme cases of lipohypertrophy. In one of those cases, we asked a surgeon to perform liposuction on a female patient. She had lipohypertrophy in the region of the umbilicus, in the thigh, and in the upper arm, because she had tried to rotate sites in order to avoid the condition, but wherever she injected she suffered lipohypertrophy. The surgeon, in this case, had to remove more than two litres of fat tissue to obtain a cosmetically satisfying result.

3. If some patients do everything right and still suffer lipohypertrophy, have patients been unfairly blamed for causing and aggravating the condition by trying to avoid painful injections?

This is a common belief, and while we found it to be true in some cases that patients would repeatedly use the same site because they found it to be less painful, they were certainly a minority. In those cases, according to our experience, it was often a lack of information or wrong advice. We had some patients who told us that they’d been informed to use only a very small area of the abdomen around the umbilicus. Under those circumstances, it’s hardly surprising that lipohypertrophy occurred.

4. Why is the abdomen particularly prone to this condition?

To my knowledge, that is not fully clear. But it is known that abdominal fat tissue responds more extensively to hormones or nutritional factors, for example. We did a study a few years ago that appeared in the Journal of Obesity in which we looked at preadipocytes (incipient fat cells) in different fat deposits and their capacity to form new fat cells. We found that the greatest capacity to create new fat tissue is in the abdomen, compared with femoral adipose tissue, for instance.

5. Apart from the appearance and inconvenience, are there any other negative effects of this disorder?

The kinetics of insulin absorption can be affected. We have observed patients in whom metabolic instability was traced to unpredictable absorption of insulin at sites of lipohypertrophy. But in my experience, this is only the case if there is some fibrotic conversion (ie. the formation of fibrous tissue). If there is only a soft swelling, there is less problem with varying absorption.

In this study, we did not want any interference on the experiment by dietary fibre (which exerts a beneficial effect on blood glucose and plasma lipid metabolism) since this might have obscured the effects of dietary carbohydrate per se. Therefore, we selected for the high-carbohydrate diet food items which did not contain large amounts of vegetable fibre (white bread, spaghetti and other types of pasta dishes, rice and potatoes). These starchy foods were consumed every day in generous servings. The diet containing 40% monounsaturated fatty acids was based on a high consumption of virgin olive oil (five to six tablespoons per day), a typical source of monounsaturated fats in Mediterranean cuisine. This was utilized for salad dressing, on toasted bread together with garlic and tomatoes (bruschetta), and for cooking meat and fish.

2. What are the best natural sources of carbohydrate and of MUFAs?

The best natural sources of carbohydrate are foods rich both in carbohydrate and in fibre, since the latter counteracts most of the undesired metabolic effects of a high-carbohydrate diet. In particular, we advise our diabetic patients to consume often legumes (beans, lentils and peas), cereals (whole-grain bread, porridge and barley), and all types of vegetables and fresh fruit (apples, oranges, grapefruit, peaches, pears and plums). Other sources of carbohydrate, but not particularly rich in fibre, are the starchy foods employed in our experiment (white bread, spaghetti, rice, potatoes), which should be utilized often but in limited amounts, since they can increase the post prandial blood glucose concentration in some diabetic patients. The best source of monounsaturated fatty acids is represented by virgin olive oil which contains significant amounts of antioxidants (polyphenols) useful for prevention of cardiovascular diseases. Other suitable sources of MUFAs are peanut and rapeseed oil and margarine.

3. Up to what limit of glucose intolerance would you recommend a high-carbohydrate diet?

A high-carbohydrate and high-fibre diet is recommended for any type of glucose intolerance, even for insulin-dependent diabetes. The only limitation is represented by the presence of hypertriglyceridemia, which is usually exacerbated by a high-carbohydrate intake. Conversely, a high-carbohydrate diet constituted in large part by starchy foods should not be recommended to diabetic patients treated with hypoglycemic drugs and insulin, and in general to patients with unsatisfactory blood glucose control and/or hypertriglyceridemia.

4. Is one type of diet best for obese NIDDM patients, and another for lean ones?

High-fat diets are more energy-dense, and therefore they are not suitable for overweight patients. Conversely, these patients will certainly benefit from a high-carbohydrate, high-fibre diet which has a low-energy density, a low energy-sparing ability, and moreover has a very good satiating effect. Therefore it might facilitate weight reduction in patients who can benefit from this therapeutic manoeuver.

Answer: The most important thing you should do is get in touch with your physician to let him know that your sugars are that high. As you know the DCCT study demonstrated that bringing the sugar average close to normal was very important in trying to prevent long term complications in type 1 diabetics. They also concluded this is probably true for type II diabetics.

If blood sugars remain elevated, patients should always check to be certain that the insulin has not expired or rendered ineffective by heat exposure. Sometimes it helps to administer insulin injections in the abdomen, which has been demonstrated to be the most reliable site of insulin absorption.

Another common cause of persistently elevated blood sugars are any types of infections. Most of these are obvious, such as upper respiratory infections or urinary tract infections. Some need to be checked out by your physician.

Also other medications (such as cortisone or certain diuretics) can cause elevated blood sugars. Other less common causes are other diseases such as thyroid or adrenal gland conditions, or a decrease in your own pancreatic insulin production. As you can see there are many reasons for persistently elevated blood sugars and it is impossible to list them all, which is why contacting and consulting your own physician is probably the most important thing you can do.

Answer: There are two types of diabetes ( type I and type II). Patients with Type I diabetes lack insulin, and need insulin injections for survival. Patients with type II diabetes have insufficient insulin or resistance of body cells to insulin action. Exercise, diet, weight loss, and oral medications can be effective in controlling high blood glucose in many patients with type II diabetes. Insulin injections are used when these measures fail to adequately control blood glucose levels.

The term “borderline diabetes” has been used to refer to type II (adult onset diabetes) patients whose blood glucose are well controlled with diet and/ or oral medications. These patients do have diabetes mellitus as diagnosed by abnormal fasting blood glucose and glucose tolerance tests. They are also at risk of future complications of diabetes. Close and continued monitoring is important to prevent worsening of blood glucose levels and to reduce future diabetes complications.

“Borderline diabetes” has also been used to describe patients who do not have diabetes mellitus. Their fasting blood glucose levels are normal, but their oral glucose tolerance test is minimally abnormal (not in levels seen in diabetic patients). These patients may have body cells that are resistant to the action of insulin, causing impaired glucose tolerance (but not overt diabetes). Some of these patients may develop diabetes later in life.

Answer. You are raising an interesting question, which is reviewed nicely in W.A. Lishman’s superb text, Organic Psychiatry, 3rd Edition (Blackwell, 1998). It is difficult to separate psychopathology attributable to diabetes mellitus (DM) from that due to poorly controlled blood sugar, hypoglycemic attacks and subsequent brain damage. For example, a study by Schwandt (1979) found that nine out of 45 unstable diabetics who had been overtreated with insulin showed mood swings, irritability, and chronic fatigue.

Apart from hypoglycemia-related disturbances, it is not clear that diabetes mellitus per se is associated with specific types of psychopathology, although fatigue, depression and irritability have been observed in some surveys. A few studies suggest a higher than expected prevalence of diabetes mellitus in psychiatric hospital populations, but this is usually the late onset, non-insulin-dependent type. Episodes of diabetic coma or hypoglycemia may contribute to brain damage and cognitive deficits, but a causal connection is not clear. There is, finally, some evidence for increased rates of depression (vs. non-diabetic populations) in patients with diabetes mellitus (see the American Psychiatric Press Textbook of Neuropsychiatry, edited by Yudofsky and Hales). Mania, on the other hand, is rare. Diabetics with major depression may benefit from use of SSRIs (Luvox, Paxil, Prozac, Zoloft), since these medications (unlike tricyclics) seem to improve glucose tolerance.