Locate the next one. The approach, treatment, and prevention of "glucose intolerance" in the context

By: Dr. Jacob Fogelman

Diabetes affects 230 million people worldwide, according to the American Diabetes Association and the International Diabetes Federation. These data indicate an increase in the prevalence of diabetes to the point of a global epidemic. In the United States alone, the disease will affect more than 48 million Americans if the current trend continues. Some 400,000 diabetics live in Israel, about 95 percent of whom have type 2 diabetes and 90 percent of them are overweight or obese. Type 2 diabetes usually begins with glucose intolerance, which usually occurs several years prior to onset of overt diabetes.

There is no family doctor who does not have a large number of patients with glucose intolerance. The Western lifestyle is characterized by excessive calorie consumption and a minority of energy expenditure by physical activity. This is one of the main reasons for the outbreak of the diabetes epidemic, the difficulty in balancing diabetes, the rise in blood pressure and the imbalance of the lipid profile. As body weight increases, insulin resistance develops and increases in blood. The key justification for the study of diabetes risk groups, such as those with glucose intolerance, is the chance of preventing future macro and microvascular complications by early intervention. Many patients also have other risk factors for cardiovascular disease, high blood pressure, and high blood fats. These patients already have evidence of metabolic disorder without complaints and clinical findings of "real" diabetes. It is estimated that the proportion of people who are in such metabolic state in Israel is about 25 percent of the population, some are unaware of their condition. When we treat a person with glucose intolerance, we are asked to give advice and recommendations about changes in his lifestyle, including changes in nutrition, physical activity and even Drug therapy. There is considerable evidence that changes in lifestyle improve not only glucose tolerance but also many other metabolic parameters. Many of us claim that despite the desire and experience to cause lifestyle changes among obese and inactive people, this is an almost impossible task. However, this argument is not always justified. In several studies it has been shown that people with sedentary and sedentary lifestyles are also willing to participate in demanding intervention programs when available. The conclusion is that type 2 diabetes can be prevented by lifestyle changes, sometimes accompanied by drug use, with time for proper explanation and follow-up of collaborating patients, even in the primary care system. The purpose of this review is to explore the therapeutic options for preventing type 2 diabetes, And check to what extent our recommendations for these changes are based on facts-based medicine. In this article, we will also review the recommended and recommended actions in primary medicine for the detection of undiagnosed diabetes patients.

Diagnosis

The diagnosis of glucose intolerance actually includes two diagnoses: IGT (impaired glucose tolerance) is achieved if the blood sugar level ranges from 140 to 200 mg / dL after a glucose loading test, after drinking 75 grams of sugar in כוס cup water. The IFG (impaired fasting glucose), which is defined as fasting blood glucose levels between 100 and 125, can also be included in this definition. Other names of glucose intolerance are also referred to as "pre-diabetic" or "hidden diabetes". The frequency of the phenomenon is enormous. A survey conducted in the United States between 1999 and 2002 found that 26 percent, 54 million Americans, suffer from IFG1. Glucose intolerance increases the incidence of diabetes. People with both IFG and IGT had a 64% prevalence of diabetes, compared to only 4.5% in people without glucose intolerance. Moreover, glucose intolerance in men without diabetes, followed by cohort study over 38 years, was associated with an increase in stroke deaths. In this study there was an increase in the incidence of cerebral stroke in patients after loading sugar had values ​​of 83 mg% and above 2. A Japanese study, based on case control study, examined 722 Japanese who had their first myocardial infarction and were compared to matched healthy individuals. Glucose intolerance (in addition to hypercholesterolemia, hypertension, and low HDL) was found to be an independent risk factor for myocardial infarction 3. In a large retrospective cohort study published several months ago that followed 18,406 non-diabetic men over a 38-year period, 1,189 deaths from stroke occurred. People with glucose intolerance were more likely to die of stroke-related causes (3A). If so, we have a medical condition that requires therapeutic treatment in order to prevent more severe morbidity in the future.

Recommendations for treatment

Current recommendations for treating glucose intolerance are: Changes in lifestyle, including changes in diet and exercise, are the treatment of choice for this condition. Dietary changes include reducing the amount of fat and white sugar and increasing consumption of fiber-rich foods, vegetables and fruits, whole grains and omega-3 fatty acids. Recommend moderate-intensity exercise (such as vigorous walking or cycling) for 150 minutes per week and weight loss of five to seven The therapeutic interventions that have been shown in randomized trials reduce the progression of glucose intolerance to overt diabetes: changes in diet, physical activity, and cessation of smoking - as noted, with decreased physical activity and a shift in the way of life Sedentary, the prevalence of diabetes increases. Randomized studies have shown that maintaining moderate weight loss by appropriate diet and exercise reduces the incidence of type 2 diabetes in people at high risk of 40 to 60 percent within three to four years. Another prospective cohort study was based on 15 years of follow-up of 7,142 middle-aged English patients (40-59) without evidence of cardiovascular disease, diabetes, or stroke 5. It was found that lifestyle changes, including smoking cessation, weight loss, and physical activity, caused the lowest rates of stroke, myocardial infarction, and diabetes in these patients over the years. Metformin at three doses per day (in Israel, To prevent diabetes, but only to treat the disease) - the drug is less effective than lifestyle changes. The NNT for this drug in the prevention of overt diabetes is 14, compared with NNT of 7 in lifestyle changes. Orlistat, three times daily, for this drug NNT of 5.4 based on two studies 7 A. roziglitazone (avandia), 8 mg once a day - Note that this drug can cause an increase in mortality due to an increase in heart disease and especially in the prevalence of heart failure. 8 A. Acarbose (Prandaz) - According to a study published in 2002 in which Israeli medical centers also participated, patients with IGT treated with acarbose were able to avoid the transition from covert diabetes Of 29 percent. It was also reported that a significant portion of the participants had also disappeared from undercover diabetes. The addition of acarbose in open diabetes can slightly improve diabetes balance but a high rate of side effects reduces patient compliance with the drug.

Nutrition recommendations

Despite the recommendation to eat whole grains in normal syrup, the recent review of the Coker 6 indicated that there were not enough good studies to support or reject this approach. The review, which will cover 11 prospective cohort studies over more than five years, evaluated the association between whole grain consumption and the incidence of diabetes. In a recent prospective cohort study of 64,191 Chinese women without a history of diabetes or other chronic diseases, the association between vegetable intake and the incidence of diabetes was examined. It was found that higher consumption of vegetables (but not fruits) caused a decrease in the incidence of the disease 7. On the other hand, moderate alcohol consumption (1 to 3 cups of alcohol per day) is associated with a reduction in the incidence of diabetes in 56-33 percent. A systematic review of 32 articles based on cohort studies and case control found that moderate alcohol consumption was associated with diabetes reduction. However, a high intake of more than three glasses per day resulted in a 43 percent increase in the prevalence of diabetes, so the recommendation for alcohol consumption should highlight these significant data and check with each specific patient his tendency to consume excessive alcohol. The American Diabetes Association recommended screening screening for diabetes in risk groups in the general population. There is not yet enough evidence to survey the entire adult population regardless of risk factors. Tools for performing the review include: fasting glucose testing or sugar loading. The risk group included people over the age of 45 who are overweight. However, the association recommended considering screening in younger populations with a family history of diabetes, HDL below 35 mg and triglycerides over 250 mg, those with high blood pressure, a story of gestational diabetes, polycystic ovarian syndrome or Clinical conditions associated with increased insulin resistance such as Acanthosis nigricans, vascular disease and sedentary living habits. Consideration should also be given to ethnic groups with high prevalence of the disease. If the sugar value is normal (<100 mg / day and 140 mg% 2 hours after eating, the test should be repeated every three years.17) Many testimonies from people with diabetes who regularly use the capsules in the Fitness factory in Kiryat Gat Eight, there has been a great improvement, and some have reported that diabetes no longer exists.

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