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By Sally Squires
With type 2 diabetes rates soaring, two medical groups advised last week that millions of high-risk Americans be screened for the disease beginning at age 30 - 15 years earlier than currently recommended.
In issuing the new screening and treatment guidelines, the American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE) said that they hoped to help curb the rising rates of complications associated with type 2 diabetes, ranging from blindness and kidney failure to heart disease and amputations.
"It is crucial to empower patients to manage their disease more effectively, thereby avoiding complications," said Helena W. Rodbard, president of the ACE.
Rates of type 2 diabetes have tripled in the last 30 years, according to the U.S. Centers for Disease Control and Prevention (CDC), largely because of the increasing percentages of Americans who are overweight and sedentary. The disease now strikes younger: Among adults aged 30 to 39, new cases of diabetes soared more than 70 percent between 1990 and 1998.
Type 2, or adult-onset, diabetes - in which the pancreas produces inferior insulin and less of it - is by far the more common form of the disease, accounting for 95 percent of cases in the United States. The 800,000 Americans diagnosed each year typically have had the disease go undetected for 10 years and half are already experiencing blood vessel complications.
Screening high-risk individuals earlier, physicians hope, will give more patients a chance to get the disease under control before complications develop. Treatment needs to be "more aggressive, complete and cohesive," said Rhoda Cobin, president of the AACE.
The endocrinologists call for high-risk individuals to get a fasting blood sugar test beginning at age 30, rather than at age 45, as the American Diabetes Association (ADA) currently recommends. Their proposal also would bring US treatment guidelines in line with those already in use in Europe.
The new guidelines also call for more aggressive monitoring of blood sugar levels once the disease has been diagnosed. They set a new, lower target of 110 milligrams for fasting blood sugar.
They also emphasize, for the first time, daily testing of blood sugar two hours after meals, when they are likely to spike, instead of the more common practice of checking blood sugar before eating. The target for post-meal blood sugar is 140 milligrams or less.
"And if they flunk that - in other words, if they have a blood sugar of 140 milligrams or more - then they need more treatment," said Paul S. Jellinger, a past president of the AACE.
Regular testing - twice a year or more - of a blood protein known as hemoglobin A1C should also be part of routine care for diabetes, the guidelines note. Unlike blood sugar levels, which can be measured at home, A1C levels are generally checked in a medical laboratory or doctor's office through a simple blood test.
A1C readings rise with increasing blood sugar and are considered one of the most accurate ways of tracking blood sugar long term.
In 1993, a landmark federal trial found that tightly controlling blood sugar levels could reduce eye and kidney complications of diabetes by up to 80 percent. Other studies have found that for every 1 percent reduction in A1C levels, there is a 14 percent to 40 percent decrease in diabetes-related complications.
The trouble is that surveys show a huge gap in knowledge about A1C among both patients and the doctors treating them. "We want A1C to be as familiar as cholesterol testing," said Claresa Levetan, director of diabetes education at the Washington Hospital Center.
How often A1C levels should be tested depends on how high the results are. The guidelines advise patients to aim for an A1C level of 6.5 - slightly lower than the 7 now recommended by the ADA. (Healthy people without diabetes have A1C levels of 5 to 6.) Patients with A1C levels of 6.5 or lower should have the test repeated every six months, according to Jellinger.
Those with higher rates should be tested every two to three months until levels drop to 6.5 or lower, and try to make corrections with improved diet and additional diabetes medication.
While the guidelines were greeted with interest by the diabetes community, they were not widely embraced. "We don't have any quarrel with the new guidelines," said Charles Clark, chairman of the National Diabetes Education Program at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and professor of medicine and pharmacology at Indiana University School of Medicine.
"But we are not yet in a position to endorse them."
On Aug. 8, NIDDK announced that it had halted a large diabetes prevention program trial a year early after results clearly showed that lifestyle changes - reducing weight by about 10 to 15 pounds and exercising about 30 minutes a day - could cut the risk of type 2 diabetes by nearly 60 percent in a group of high-risk people one step short of having the full-blown disease.
An expert panel convened by the National Institutes of Health (NIH) and the CDC is reviewing those results before issuing its own set of treatment and screening recommendations.
"We want to see what the NIH and the CDC [expert panel] does," Clark said. "What we don't want to do is to have different standards. We want a consensus so that doctors and patients don't get confused."
In the meantime, Clark said, there is no harm in high-risk individuals' going ahead with screening, after discussing it with their doctor. "It's not a bad idea to get a blood sugar test," he said. "This is a staggering public health problem."
The ADA also said that it seems "reasonable" to screen high-risk individuals at age 30, rather than 45 as the organization currently recommends, but noted that the endocrinologists' new guidelines for A1C and for testing blood sugar after meals are still under review. "We'd like to look at what their rationale is in detail before making recommendations," said ADA spokesman Jerry Franz.
Washington Post August 28, 2001; Page HE01
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