You remember that fable, don’t you? The one where six blindfolded men each describe an elephant - or at
least the part he could reach. One said the elephant was a fan (the ear), another said it was a giant snake (the trunk), another said it was a tree trunk (the leg), and so on and so on. Well, the diabetes news this week has been similar - lots of people describing one piece of the puzzle from different corners of the research world. Here at Doc Gurley, we think it’s time to take off the blinders and look at the whole picture. Like an elephant in the room, it’s pretty impressive.
1) New Zealand researchers discover that, even in you’ve never had a diagnosis of diabetes, your chances of dying go way up if your blood hemoglobin A1C is elevated. Most alarmingly, the death response is dose-related, so the higher your blood test, the greater your chance of dying. And this study found people dying even though the researchers didn’t follow them for that long - only 3-5 years after one blood test. How bad was it? “In those without known diabetes at baseline, a 1% increase in A1C level was associated with a 16% increase in mortality rate.” Sheesh. This is serious news for everyone - including those of us walking around thinking that all this diabetes stuff doesn’t apply to us. Maybe it does - in the most crucial way imaginable.
2) Now that you’re paying attention, you may be asking What the heck is a hemoglobin A1C test, anyways? If so, you get Doc Gurley extra credit points. Hemoglobin A1C is a test that doctors like, while the standard prick-your-finger random glucose test is the one that diabetic patients can do themselves. Hemoglobin A1C looks at glucose levels over the past 3 months - by looking at your red blood cells. It gives a rough measure of how elevated (over time) your sugar has been. A finger-stick glucose is a random pinprick to see what your sugar level is right this minute. One blood test doesn’t translate into the other, which is a huge problem for doctors and patients when they’re talking about two different values, with two different implications. Until now that is - researchers created a conversion value, one they’re calling the estimated average glucose. Lots of diabetes organizations are waving pom-poms, trying to get everyone to switch over to using the estimated average glucose. It may, however, take more than cheerleading to get everyone using this value, if their description of it is any clue. Get a load of this explanation - the average is calculated “by combining weighted results from at least 2 days of continuous glucose monitoring performed four times, with seven-point daily self-monitoring of capillary glucose performed at least 3 days per week.” Anyone understand that? patient? doctor? Anyone?
3) So now we’re stepping back and gazing at the elephant stage. We’ve got an important blood test that may predict your chances of dying in just a few years (even if you don’t have a diabetes diagnosis), we’ve got an uber-geek conversion factor for calculating that blood test based on fingersticks that diabetics can do themselves. Are we now overwhelmed and depressed? Heck no - that’s because our third recent diabetes news item is from those hilarious, hope-inspiring people (you guessed it) - Finnish researchers! Huh? That’s right. The Finnish Diabetes Risk Score is big news - researchers have found a set of easy, simple, non-invasive questions that anyone can use to determine your risk of developing diabetes. And, if that wasn’t good enough, they went to the next step and looked at whether or not changing the lifestyle of people at risk reduced or delayed the onset of diabetes. The answer was an overwhelming Yes! You Can! The people with the biggest response to lifestyle changes were actually those who were older, and those who scored the worst. If that’s not hopeful, good news, then what is?
Here’s the huge, pachyderm punchline - if your weight is creeping up, if you’re worried you’re at risk for diabetes, there are simple ways to find out if that’s true. Check out the Finnish Diabetes Risk Score for yourself. And, when you go in for a check-up, even if your fingerstick glucose is fine, ask your doctor for a hemoglobin A1C test (print up the article and take it with you if need be). And if, heaven forbid, your hemoglobin A1C test is elevated, you’ll now have lots of motivation to make those lifestyle changes that we all should probably be making (whole grains, better diet, more exercise) - but this time you’ll stick with it. Because now, more than ever, you know there’s good evidence that what you’re doing could save your health, and even your life. This week’s diabetes news, when you look at it all together, takes on elephant-sized importance - a crucial test, a better way to compare results, and effective change for people at risk.
If that’s not big, what is?
Addendum: If you have trouble getting to the specifics of the Finnish Diabetes Risk Score, here are some more details about how it’s done, and links -
Here is the original article describing the exact components of the Finnish Diabetes Risk Score. It is made up of seven parts – your BMI (calculated from your height and weight), your waist circumference, your age, any history of high blood pressure or high blood sugar, information about daily consumption of fruits, berries, or vegetables, and information about physical activity. The questions are impressively specific and clear-cut – for example, the physical activity questions are “do you, in your spare time, read, watch TV, and work in the household with tasks that don’t strain you physically?” If the answer to that is yes, the next question is - “is your work mainly done sitting and does not require much walking?” A yes to both questions puts a person is a low exercise category. A combination of results on all seven of these factors decides your Finnish Diabetes Risk Score.
Doc Gurley is a Board-certified Internist physician and the only Harvard Medical School graduate to have been awarded a Shoney’s Ten-Step Pin for documented excellence in waitressing. 
8 responses so far ↓
Ian Furst // Jun 16, 2008 at 5:58 am
Good post — I tried to get to the Finnish score but it’s password protected.
Doc Gurley // Jun 16, 2008 at 8:33 am
I’ve put the specifics of the Finnish Risk Score (and some more links) into an addendum to the article. Hope that helps you reach the info.
Helen Howes // Jun 16, 2008 at 12:08 pm
Whole grains are not better for diabetic or pre-diabetic people. There is much evidence that the GI is less helpful than the GL for us too. No grains seems to be nearer the ideal… Exercise and weight loss definitely help, but the biggest risk factor (not addressed) is genetic - there is a strong familial connection, particularly if one’s mother, father, or grandparent had the disease…
Doc Gurley // Jun 16, 2008 at 1:14 pm
Actually, Helen, the data strongly disagree with you. Below are a very few of the many studies that show that whole grains are associated with a reduced risk of type 2 diabetes and cardiovascular disease. Studies also overwhelmingly show that whole grains improve a sense of fullness (satiety) and help with weight loss because of it, as well as blunting spikes of elevated glucose throughout the day, even if only eaten at breakfast. No one who is diabetic should be eating massive amounts of carbs (whole or not) – but whole grains are an important part of a healthy diet for everyone.
A few of the many studies:
Nilsson AC, Ostman EM, Holst JJ, Björck IM.
Including indigestible carbohydrates in the evening meal of healthy subjects improves glucose tolerance, lowers inflammatory markers, and increases satiety after a subsequent standardized breakfast.
J Nutr. 2008 Apr;138(4):732-9.
Priebe MG, van Binsbergen JJ, de Vos R, Vonk RJ.
Whole grain foods for the prevention of type 2 diabetes mellitus.
Cochrane Database Syst Rev. 2008 Jan 23;(1):CD006061. Review.
Kochar J, Djoussé L, Gaziano JM.
Breakfast cereals and risk of type 2 diabetes in the Physicians’ Health Study I.
Obesity (Silver Spring). 2007 Dec;15(12):3039-44.
Nilsson AC, Ostman EM, Granfeldt Y, Björck IM.
Effect of cereal test breakfasts differing in glycemic index and content of indigestible carbohydrates on daylong glucose tolerance in healthy subjects.
Am J Clin Nutr. 2008 Mar;87(3):645-54.
Clark CA, Gardiner J, McBurney MI, Anderson S, Weatherspoon LJ, Henry DN, Hord NG.
Effects of breakfast meal composition on second meal metabolic responses in adults with Type 2 diabetes mellitus.
Eur J Clin Nutr. 2006 Sep;60(9):1122-9. Epub 2006 May 3.
Barclay AW, Petocz P, McMillan-Price J, Flood VM, Prvan T, Mitchell P, Brand-Miller JC.
Glycemic index, glycemic load, and chronic disease risk–a meta-analysis of observational studies.
Am J Clin Nutr. 2008 Mar;87(3):627-37. Review.
Krishnan S, Rosenberg L, Singer M, Hu FB, Djoussé L, Cupples LA, Palmer JR.
Glycemic index, glycemic load, and cereal fiber intake and risk of type 2 diabetes in US black women.
Arch Intern Med. 2007 Nov 26;167(21):2304-9.
Michael Maison // Jun 16, 2008 at 7:52 pm
You are right (as usual) Doc Gurley. Another “coup de grace” study on the subject of whole grain intake and diabetes/cardiovascular protective benefits:
American Journal of Clinical Nutrition, Vol. 76, No. 2, 390-398, August. Whole-grain intake is favorably associated with metabolic risk factors for type 2 diabetes and cardiovascular disease in the Framingham Offspring Study1,2,3,4 Nicola , McKeown, James B Meigs, Simin Liu, Peter WF Wilson and Paul F Jacques.
Liana // Jun 17, 2008 at 3:32 pm
Hmm… interesting. I read the study, and what I got out of it was more so that a lot of people are running around out there with undiagnosed diabetes, and undiagnosed diabetes will kill you.
Of note, 71% of the participants were Maori. Significantly more at risk of diabetes and metabolic syndrome than Caucasians for example. So it’s not really clear to me how well this would apply to Caucasians since they weren’t able to tease out other cardiovascular risk factors.
Are there any studies that suggest that a HbA1c is better than, say, a 2 hour OGTT or fasting plasma glucose for diagnosing diabetes?
Doc Gurley // Jun 17, 2008 at 4:24 pm
The HgbA1C study was specifically designed to look at non-diabetics, but included some diabetics anyways. The authors state that in prior studies with diabetics “A1C levels have also been associated with mortality in patients with type 1 diabetes and nondiabetic chronic kidney disease and with incident cardiovascular disease.” Of the 408 diabetics in this study, “Although mortality rate was also increased in participants with a previous diagnosis of diabetes, this was only partially explained by their increased A1C levels.” - possibly due to smaller numbers. My Doc Gurley take on this question is that elevated HgbA1C is bad for everyone, but sneakier and previously-unrecognized as potentially lethal in non-diabetics. To answer your final question, the HgbA1C test is unique in that it is 1) much easier to do than either a 2 hour OGGT or fasting glucose (as this study proves, where HgbA1C was done as part of a hepatitis screening campaign) and 2) has unique properties in that it looks for elevated blood glucose levels averaged over the preceding three months. All other glucose tests just look at your blood “now” but don’t say anything about your blood sugar over time. “Better” is a relative measure of a test- and in this case HgbA1C’s much, much better at picking up what your body has been exposed to for the last three months.
Liana // Jun 20, 2008 at 9:38 am
Thanks, Doc.
In our health region, we get told off for ordering HbA1c for diagnosis… so I use it to monitor treatment, and also to decide when to start right away with meds instead of giving a 3 month trial of exercise and lifestyle. Maybe with this new study, they’ll reconsider?
I agree that the HbA1c is a lot easier… no fasting required. However, in the Canadian Diabetes clinical practice guidelines, they say that the lack of standardization with the HbA1c test makes it less useful for diagnosis, and they also mention that a FPG of 7.0 or OGTT of >/=11.1 are most predictive of microvascular damage (alas, no mention of macrovascular damage).
Of course, the guidelines are from 2003 and updated guidelines are going to be released in the fall so who knows if they will change their tune? I’m eager to see what changes they recommend.
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