Fighting Diabesity

Chances are increasingly slim that the country will escape the twin epidemics of diabetes and obesity if present trends continue. More than 20 million Americans already have diabetes, and more than 60 million Americans are obese. The two conditions have become so intertwined that experts recently coined a term to describe their relationship: diabesity. 

Although Americans have made significant progress in understanding diabesity, they also face significant challenges in fighting it. Proposed cuts to federal funding for diabetes prevention and research may hinder efforts to learn more about the disease. Moreover, successfully overcoming diabesity may require major changes in life-style that face stiff cultural resistance.

The situation may not be as hopeless as it appears, however. Since the 1990s, scientists have come a long way toward understanding diabesity. “There is a lot of research at the basic, clinical, community, and public health levels,” says Francine Kaufman, MD, professor of pediatrics at the University of Southern California (Los Angeles) and past president of the American Diabetes Association (ADA; Alexandria, VA). “The problem is getting what we learn into practice.” This year, many public health experts are making that their number one priority.

DEFINING DIABESITY

Diabesity is a two-part concept. The first part is that obesity drives the diabetes epidemic. The second is that obesity and diabetes are critically linked.

Statistics show that the rate of obesity in the United States has grown markedly since the 1970s. According to data from the National Health and Nutrition Examination Survey (NHANES) and the Centers for Disease Control and Prevention (CDC; Atlanta), the age-adjusted prevalence of obesity doubled from 1976 to 2002. The latest data show that 30% of adults were obese during 1999–2000, compared with 15% of adults during 1976–1980. The number of people who were overweight or obese also jumped, rising from 47 to 65%.

A particularly troubling sign is the rate of obesity among young people, many of whom are now beginning to develop type 2 diabetes (formerly known as adult-onset diabetes). NHANES and CDC data show that the number of overweight children grew from about 5% during 1963–1970 to 16% during 1999–2002. According to CDC, the latest data suggest that the rise in overweight children has not leveled off yet and is still increasing.

Contributing factors to childhood obesity include genetic influences, access to unhealthy foods, and lack of physical activity. Additionally, because obesity is becoming more common, public perceptions about what constitutes a healthy weight are changing. For instance, a new study from Northwestern University (Chicago) published in the March 2006 issue of Pediatrics notes that only 36% of parents in a study of 223 children correctly thought their child was overweight or at risk of becoming overweight.

Statistics also show that being overweight or obese is directly linked to diabetes. According to data from the U.S. Department of Health and Human Services (HHS; Washington, DC), a person who gains 11–18 pounds will increase his or her risk of developing type 2 diabetes to twice that of someone who has not gained weight. Moreover, about 80% of people with diabetes are also overweight or obese. Given the rising rates of obesity in the United States, experts predict the number of diabetic Americans to rise precipitously in the years ahead.

DIET AND EXERCISE

While genetic influences play a part in the development of diabesity, diet and exercise are key variables that can influence the likelihood that someone will become obese or diabetic. “Improving diet has a tremendous effect,” says USC’s Kaufman, who adds that changes in life-style have been shown to reduce the incidence of diabetes by 60%.

Several recent studies confirm the importance of diet and exercise. For instance, in research published in the January 2005 issue of the Lancet, researchers who studied the dietary habits of more than 3000 young adults over a 15-year period found that “fast-food consumption has strong positive associations with weight gain and insulin resistance, suggesting that fast food increases the risk of obesity and type 2 diabetes.”

In another study, which appeared in the February 2006 issue of Diabetes Care, researchers found that obesity doesn’t just accelerate the development of type 2 diabetes; it also may hasten the onset of type 1 diabetes in young patients with compromised pancreatic beta cell function. “The increasing prevalence of childhood obesity may substantially account for the younger age at onset of type 1 diabetes observed in various populations,” wrote the researchers.

The link between life-style and diabetes is also well established. In a study published in the February 2, 2002, issue of the New England Journal of Medicine (NEJM), researchers assigned more than 3000 people with elevated plasma glucose concentrations three treatments: a placebo, 850 mg of the diabetes medicine metformin, or a life-style modification program. After three years, the life-style modification program cut incidence of diabetes by 58%, while metformin only led to a 31% reduction compared with the placebo.

The NEJM trial and other studies suggest that while there are a number of approaches to maintaining a healthy weight and lowering the risk of developing diabetes, including medication or nutritional supplementation, dietary changes and physical exercise can greatly improve the odds of success.

CHALLENGES

Experts hope to learn even more about diabesity and increase public awareness of the condition in the years ahead. Unfortunately, there are some challenges. Lack of government support for antiobesity programs may be one of the biggest obstacles. Earlier this year, the ADA warned that the federal government has announced plans to cut $11 million from the National Institutes of Health’s (NIH; Bethesda, MD) National Institute of Diabetes and Digestive and Kidney Diseases, and $20 million from the CDC. According to ADA president Robert Rizza, MD, the cuts would harm state-based diabetes control programs.

“The ADA strongly disapproves of the administration’s efforts to reduce funding for diabetes research and prevention at NIH and CDC,” Rizza said on February 6. “By any measure, diabetes is a disease that requires great federal attention, yet the administration’s response is to weaken the federal resources needed to fight this national epidemic.”

The ADA plans to mount a campaign in June to persuade Congress to restore funding. “All of us want to look back a year from now and see that 2006 was the year that the administration and Congress recognized there is a nationwide diabetes epidemic and they took meaningful steps to fight the epidemic,” Rizza said.

The federal budget isn’t the only problem, however. A lack of state government support may be making things even worse. According to a 2004 analysis of state efforts to control childhood obesity by researchers at the University of Baltimore’s Schaefer Center for Public Policy, state governments have been slow to respond to the crisis, with 23 states receiving a failing grade.

The absence of government support doesn’t bode well for efforts to curb diabesity. City planners, government bodies, schools, communities, and employers all must participate to fully address the problem, says Kaufman.

Another concern of diabesity experts is that some of the methods that they rely on to fight diabetes are no longer working. Last December, William Cefalu, MD, a diabetes researcher at the Pennington Biomedical Research Center (Baton Rouge, LA), proposed lowering target values for the A1c test used by doctors to determine blood sugar levels. In an editorial in the December 22, 2005, issue of NEJM, Cefalu wrote that although doctors typically recommend a score of 7% for their diabetes patients (6% is considered normal), a lower score would be better. He also called for lowering the current 8% recommendation for children ages 6–12 and 7.5% recommendation for teens aged 13–19.

“The medical community needs better means, different strategies, and a different mind-set if we hope to improve and maintain glycemic control in patients with type 1 diabetes and minimize side effects,” according to Cefalu.

Researchers are also rethinking some other tools thought to be helpful, such as the glycemic index. A new study published in the February 2006 issue of the British Journal of Nutrition suggests that there was no significant correlation between the glycemic index of foods and the blood sugar levels of more than 1000 individuals who answered food questionnaires for five years. While the data raised questions about the effectiveness of the glycemic index, other researchers have called for more study.

BLOOD SUGAR PRODUCTS: A BAKER’S DOZEN

While health experts suggest that diet and exercise are the best ways to ward off diabesity, functional foods and nutritional supplements also offer many benefits. What follows is a list of 13 food and supplement ingredients that may have a positive impact on blood sugar levels and other health problems associated with diabesity.

1. ChromeMate, from InterHealth Nutraceuticals (Benicia, CA), is a niacin-bound chromium compound that mimics glucose tolerance factor, a biologically active form of chromium found in nature. At a meeting of the Federation of American Societies for Experimental Biology (FASEB) in April, Debasis Bagchi, PhD, InterHealth’s vice president of research and development, presented data from a study showing that ChromeMate inhibited the secretion of IL-6, a cytokine known to reduce insulin sensitivity.

2. Super Citrimax, another product from InterHealth, targets weight control and insulin resistance. An extract from the herb Garcinia cambogia, Super Citrimax is a unique form of (-)hydroxycitric acid that may assist weight loss and boost serotonin levels. In a second study presented at the FASEB meeting, Super Citrimax was shown to decrease oxidative stress and insulin resistance while increasing brain serotonin levels in obese Zucker rats. According to Bagchi, the extract influences several weight-control mechanisms. “It affects appetite suppression and also checks cortisol secretion,” Bagchi explains. “By changing those parameters, it helps to regulate obesity.”

3. Chromax, a special form of chromium picolinate from Nutrition 21 (Purchase, NY), was shown to help muscles use blood sugar more efficiently in a small animal study published in the February 2006 Journal of Nutrition. In the 16-week study, rats that received chromium picolinate had improved ratios of triglycerides and high-density lipoprotein. William Cefalu, MD, chief of the division of nutrition and chronic diseases at the Pennington Biomedical Research Center (Baton Rouge, LA), notes that previous research had already suggested that chromium picolinate could improve insulin resistance. “This animal study is significant because it suggests a more detailed mechanism of action for chromium on improving insulin sensitivity in muscle,” Cefalu says.

4. Lakanto-S, a zero-calorie sweetener from Saraya Company, Ltd. (Osaka, Japan), is derived from luo han guo (Siraitia grosvenori) fruit and the sugar alcohol erythritol. Lakanto-S tastes and looks like brown sugar, and it’s also free of artificial colorings and additives. The company recently unveiled the product at this year’s Natural Products Expo West in Anaheim in March. “Obesity is now a significant health challenge in America, which means more and more people are looking for chemical-free sugar substitutes that also taste good,” says Margarita Valou, president of Saraya’s Canadian division. “Lakanto-S is extremely popular with diabetics and dieters in Japan, and we expect a similar response here in the United States.”

5. Cinnulin PF, a cinnamon extract from Integrity Nutraceuticals (Sarasota, FL), has been studied by researchers from the U.S. Department of Agriculture (Washington, DC) who have been investigating cinnamon’s hypoglycemic effects. In one placebo-controlled trial by USDA researchers published in the December 2003 issue of Diabetes Care, volunteers who consumed 1–6 g of cinnamon per day for 40 days improved their blood sugar levels. Moreover, in an unpublished trial conducted by the Ohio Research Group (Wadsworth, OH), volunteers who took Cinnulin PF experienced lower fasting blood glucose levels and an increase in lean body mass.

6. Bitter melon (Momordica charantin) contains several compounds that may have a positive effect on blood sugar levels, including charantin, vicine, peptides, and polypeptide-P, according to FulLife Natural Options Inc. (Boca Raton, FL), which distributes bitter melon supplements and teas sold under the brand name Charantea.

7. Guggulez 100, from Creative Compounds (Scott City, MO), was developed in response to demand for high-quality guggulsterones that have thermogenic and cardioprotective effects. The active components of the Commiphora mukul plant, E and Z guggulsterones are believed to help stimulate thyroid function. Natural guggulsterones are available in 2–4% extracts but require a dose of 1 g or more to be effective. Guggulez 100 contains both E and Z guggulsterones in a 60:40 ratio that only requires a 25–75 mg dose.

8. Shugr is a mixture of several naturally occurring sweeteners, including erythritol, maltodextrin, and tagatose. According to Albert Bustos, public relations manager at DNP International Inc. (Whittier, CA), Shugr also has prebiotic properties. “Shugr tastes, cooks, and bakes like sugar, and it even rises, browns, and caramelizes,” Bustos says, adding that a trace amount of sucralose provides a high note to the flavor of Shugr.

9. Stevia (Stevia rebaudiana), another alternative sweetener, is derived from a plant native to Paraguay. “Stevia is an extract derived from stevia leaves containing 90% minimum total steviosides,” says DNP’s Bustos. “One of stevia’s greatest attributes is that it contains no calories or fat.” However, Bustos adds that it is not generally recognized as safe (GRAS) for use in foods and beverages and must be labeled as a supplement.

10. Barliv, from Cargill Health and Food Technologies (Minneapolis), is a barley beta-glucan extract that helps promote healthy cholesterol and blood sugar levels. At the First International Congress on Prediabetes and Metabolic Syndrome in Berlin last April, researchers from the University of Minnesota Medical School (Minneapolis) presented research showing that barley beta-glucan improves levels of low-density lipoprotein cholesterol, triglycerides, and several markers of glycemic control. Barbara Bentson, Cargill’s director of regulatory affairs, says “there is growing evidence of barley’s health benefits.”

11. Beneo inulin and oligofructose fibers, supplied by Orafti (Malvern, PA), are fermented by beneficial bacteria in the colon, so they are lower in calories than sugar and don’t increase blood sugar levels. Orafti’s Beneo 95, a short-chain inulin fiber, was shown in a small pilot study to produce higher levels of satiety after meals and to reduce hunger. “Beneo P95 is recommended for diabetic formulations because it provides some sweetness without the sugar,” says Joe O’Neill, national sales manager at Orafti. “Also it’s a fiber, so it is reduced in calories versus sugar and provides additional health benefits such as enhancement of digestive health.” Anne Franck, Orafti’s vice president of science and technology, adds that the study’s use of oligofructose to tackle obesity is a novel approach. “This should allow manufacturers to use Beneo oligofructose to increase the satiety potential of their food products,” she says.

12. GlucoTrim, Soft Gel Technologies Inc.’s (Los Angeles) extract from the herb Lagerstroemia speciosa, is supported by clinical trials in Japan and one clinical trial in the United States, according to Yousry Naguib, PhD, technical services manager at Soft Gel Technologies. Naguib says that in the U.S. trial, volunteers with type 2 diabetes who received daily doses of 32 mg and 48 mg for two weeks showed significant improvement, adding that subjects who received supplements in softgel rather than hard-shell form showed even greater improvement. “The softgel formulation might have a better bioavailability than the dry powder,” he explains.

13. Whole Grain Soy Flour contains more dietary fiber than whole wheat and may have a beneficial impact on several health problems associated with diabesity. According to Terry Gieseke, director of business development at Nutriant Soy Ingredients (Cedar Falls, IA), which manufactures a wide range of soy products, soy protein enhances satiety and helps with weight management. “Nutriant soy ingredients can help manufacturers develop great-tasting everyday foods that are lower in trans and saturated fats, offer a good-to-excellent source of protein, and are a good-to-excellent source of fiber,” Gieseke says. “These foods can also be low in calories for those targeting weight management.”

TURNING A CORNER

Despite the challenges faced by the public health community, there is reason to be optimistic. Since the discovery of the hormone leptin in 1994, researchers have learned a great deal about obesity. Scientists are excited about the latest research, and their findings are likely to spread excitement among the public as well.

In fact, some changes are already taking place. Last summer, intense public pressure led member companies of the American Beverage Association (Washington, DC) to voluntarily remove soft drinks from some schools. Several states recently passed laws that require schools to serve more healthy food and limit access to sodas and snacks. And on March 6, more than a dozen members of Congress, including Senator Tom Harkin (D–IA), called on HHS to monitor junk food advertising aimed at children.

These small but meaningful changes suggest that cultural attitudes about obesity are changing. What was once seen as a personal issue is now seen as a public health problem. In other words, the fight against diabesity may have just gotten a little easier.