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 DIABETES

Abstract:  The risk of Type 2 diabetes that comprises 90-95% of those with the disease is substantially related to body weight and life styles at age.  Those overweight or obese are highly likely to suffer the disease at their age progresses.  Other factors that can substantially determine risk are diet, cardio fitness, smoking habits, and blood pressure. A family history of the disease can increase risk by up to many times.  The disease is thus highly preventable by good health habits.  Men that obtain diabetes incur a two to three fold increase in risk of heart attack and stroke, and this elevation in risk increases steadily with duration of the disease.  Women that obtain diabetes can suffer five or more times higher risks of heart attack and stroke as duration of the disease continues.   Diabetes is a most unwelcome disease that can require continuous care and monitoring of diet.  Few people today know much about their risk of getting diabetes, and how this risk develops.  The paper that follows describe these risks and provide actual tables of the major contributing research findings.  The development of diabetes risk described following is in present Version #3. But the information here can help health-interested persons in understanding more about their risks of diabetes and how they may avoid suffering it

Background:  Diabetes results from abnormal levels of sugars or glucose buildup in the blood. A most serious form called Type 1 formerly called juvenile diabetes results when the body fails to make the insulin that controls blood glucose.  Type 1 tends to be genetic, often starts in childhood, and involves 5-10% of those that develop the disease. Type 2 or adult onset Diabetes that afflicts 90-95% of individuals usually occurs later in life when the body becomes resistant to the effects of insulin in controlling blood glucose. Most of the information that follows pertains to risks of the most important Type 2 that also is called Non-Insulin Dependent Diabetes. Nearly 1/3 of the 18 million people in the US that now have diabetes appear to be unaware that they have the disease. As will follow here, publicity about risks of diabetes has been sadly neglected.  The risks of getting it are very substantially related to lifestyle habits of weight, diet and exercise, and few people today that do not have diabetes are aware of the extent of its risks, of its very harmful effects on wellness days of life, and what they need to do to avoid suffering this most unwelcome disease.

Diabetes produces two thirds of its related major illnesses and deaths by substantially increasing the risk of heart disease and stroke. An impressive demonstration of this is cited herein from two of the largest-yet population studies in Diabetes and Heart Disease, A Global Analysis  This shows that for men, the presence of diabetes initially increased heart disease risk by 1.6 times.  But this effect grew larger the longer the diabetes persisted, and raised heart disease risk to 2.8 times after 20 years and to 3.7 times after 30 years of duration. For women, it increased heart disease risk initially by 2.3 times, but increased risk of this major killer 4 times after 10 years, 5.8 times after 20 years, and a shocking 11 times after 30 years. The higher ratios for women than for men were because women have much lower base risks of heart disease than men during earlier years of life.  The presence of diabetes erased women's lower risk of heart disease.  Recognizing that risk of heart disease also increases substantially as age progresses, this additional multiplier of risk for diabetes with duration of its existence that also moves up with age can result in extremely high and often fatal risks of heart related diseases as people that contracted diabetes earlier pass ages 50 and 60.

But in addition to increasing risk of today's major killer of heart disease, diabetes also terminates life prematurely via both by itself and via other causes.  These risks due to diabetes per se alone can comprise the 5th largest terminator of life in the US.    Most people with Type 1 diabetes and about 20% of those with Type 2 also will become legally blind.  The extent of diabetes in the US had increased 6 fold during the past four decades, and is increasing world wide.  It has been estimated that 1/3rd of children born today may suffer it during their lifetimes. 

Doctors classify cause of death by a primary cause.  Those included in current US health statistics of the NIH (National Institutes of Health) for diabetes include not just those classified as diabetes per se but but also include others classified as heart and cardiovascular diseases and as nephritis or kidney disease. The specific primary cause of a premature death designated by a doctor sometimes can be arbitrary. Life Ahead identifies risk of major disease and death via these classifications of the NIH.  But people must develop those actions that reduce risk of multiple causes of major illness and death, and a major problem to be avoided in the pursuit toward health is that of reducing risk of having diabetes. The same things that reduce the risk of having diabetes also reduce the risk of suffering heart disease and premature death for those that now have the disease. .The discussions following provide a most extensive analysis of the factors that produce diabetes.  An excellent source of more general information about diabetes is found on the web site of the American Diabetes Association:     http://www.diabetes.org/about-diabetes.jsp

There has been a change in the bases for diagnosing diabetes in recent years.  The most recent "ADA" recommendations approximate:

• Fasting plasma glucose is equal to or greater than 126 mg/dl;

• Diabetes symptoms exist and casual plasma glucose is equal to or above 200 mg/dl; or
• Plasma glucose is equal to or greater than 200 mg/dl during an oral glucose tolerance test

Previously a glucose tolerance test was used that measured values before and after taking a glucose drink  Most research reported to date involved individuals tested with previous definitions that were a bit more restrictive than those current.  An earlier guideline was a fasting glucose of 140 mg/dl.  Much available research about risks of diabetes is based on use of their earlier guide, and today's diagnosed extent of diabetes should be somewhat higher than that identified in research that used the earlier guide.

Managing diabetes is a problem needing the care of the doctor, and is beyond the scope of the Life Ahead program that helps people achieve better health from their own life style habits. But the importance of lifestyle habits in reducing risks of ever experiencing the disease, and for vastly reducing the health risks of those that do have it are enormous. The discussion that follows first involves how various life style factors produce diabetes.  Following this will be the effect of lifestyle factors for those that have diabetes in suffering further from it.  Diet has been the all-important diet factor factor usually first considered.  But other factors that are less well recognized can be of similar importance to risk of obtaining and suffering further from this disease. And few people without diabetes seem to understand well their risks of obtaining this unwelcome disease.

Diabetes is a very complex disease.  No serious scientific level quantification of its overall risks as is included following has been found either on the internet or in the conventionally published health journals. The full picture of diabetes risk to life is partly invisible to conventional health statistics because deaths from it can mostly distribute to other listed causes.  Life Ahead via its life-cycle multifactor capability may provide a first method for identifying overall diabetes risks to disease and early death from its many involved lifestyle factors, and value how these risks can be reduced. Some results this new analysis follow:

AGE, LIFE STYLE and the RISK of SUFFERING DIABETES

Diabetes, Age and Body Weight:  The risk of suffering diabetes increases sharply with age, and are generally similar for both men and women.  The # 1 lifestyle risk is that of body weight as measured by the BMI.  Risks of getting diabetes for men and women of various ages and body weight are in the table following: Weights are shown for men and women of 5'-8" and 5'-4" height respectively. The values for a BMI of 26 represent those for the US NIH health statistics for our average non-smoking population.

Body weight and overweight is by far the #1 usual health factor that determines the  risk of contracting diabetes. In fact, the effect of body weight on the risk of diabetes may be largest effect of any single health factor on any single outcome studied in the Life Ahead Project.  This is shown by the results of very large studies A1 and A3 that are appended. Highest levels of weight for height measured as BMI in these actual studies increased risk vs low BMI values  by 41 times for men and 63 times for women.  Study A2 confirmed that very obese people that lost large amounts of weight reduced their risks of getting diabetes by two thirds. 

This key research reveals that people that are substantially overweight are near certain to suffer diabetes if they reach certain ages. And those ages can be less than 50. The above results for a BMI of 34 assume a risk ratio of only about 15 between lowest and highest BMI risk. Yet the actual risk ratios obtained by studies A1 and A3 range up to a far higher 41 to 63 to one.  And as will follow, these risks can increase much further from inadequate exercise, smoking, blood pressure, diet, and family history of disease. 

The large increase in Type 2 diabetes risk from being overweight plus its further risks from other factors suggests that this is a disease that can be almost entirely self-inflicted by lifestyle habits. There is no clear reason known why weight per se should have such a large effect on risk of diabetes. It is plausible that this risk may  be caused by dietary habits over long time that generated added dietary glycemic load from consistently more food intake than that needed to sustain healthful weight. This in turn developed the higher than usual insulin levels that in turn created the insulin resistance that produced diabetes. 

Diabetes and Waist Size:  Another factor that appears to be even more important to risk of diabetes than the BMI is the simple measure of waist size or circumference. This result of multiple research studies most recently was confirmed by the study of 884 diabetes cases obtained on the 27,000 US Health Professionals appended as study B1. Risks for the highest 5th of this population for BMI were 7.9 times for BMI, and 12 times for waist size. A still more accurate effect derived from the data in this study is obtained for a combination of results from both BMI and waist size. Formulas relating waist size to risk of diabetes are appended following the tables.  This waist size measure is not now used in Life Ahead because it is more generally useful and adequate to use the BMI,  but this striking effect further confirms the enormously important risk of diabetes from being overweight.   

Diabetes, Exercise and Cardiofitness:  Doing the exercise that improves cardiofitness regularly and continued over life is another important thing that can reduce health risks from diabetes. Exercise helps in two different ways.  First, it can reduce the likelihood of ever suffering Type 2 diabetes.  And second, for those that do have the disease, proper exercise can substantially reduce risk not only death from diabetes per se but from suffering those key problems of heart disease and stroke.  The Table appended lists results of the important  research studies found published on risks associated with diabetes, exercise and cardiofitness. Studies C1, C2, and C3 show that at least 30% and perhaps 40% of those that now suffer diabetes probably would not suffer it if they maintained a reasonable program of cardiovascular-effective exercise.  These results were obtained by individuals that accomplished quite modest probable improvements in probable cardiofitness of 8-10% or just  8-10 units of CFR or cardiofitness ratio. This improvement is easily obtainable from a moderate program of quite brisk walking for an hour or hour and a half each week.  Although no study to date has explored the benefit a higher fitness improvement of say 20 units CFR, it seems possible that a more active exercise program might reduce the risk of ever suffering diabetes in half.  Exercise programs conducted on those with diabetes have shown that these can reduce insulin sensitivity and improve glucose tolerance, and move some from continuing to have diabetes.  Life Ahead now values risk of obtaining diabetes from cardiofitness in CFR.  For CFR levels of 90, 103, 110, and 120 respectively these risk ratios are 1.7; 1.0; 0.74, and 0.48. 

But in addition to the effect of regular exercise in reducing diabetes per se, even more impressive results are shown in the appended Table for those that suffer the disease. Study N1 found a 54% reduction in risk in the large Nurses study for best exercise, and study N2 found nearly a 40% reduction in risk of all cardiovascular disease in the large men's Health Professional Study. Study C1 confirmed the benefit for stroke, and P2 showed that good measured improvements of cardiofitness reduced risk of death from all causes by 2/3rds. This in turn directly confirms a substantial extension of healthy life expectancy. As for the more extensive results on healthy persons (Cardiovascular Disease and Cardiofitness), the benefit appears best related to improvements in cardiofitness.  The values of actual and estimated cardiofitness relate more closely to the CFR than to estimated calories of exercise. Although these risk ratios for those with diabetes are similar to those obtained on healthy persons, the actual level of cardiovascular risk for those with diabetes typically can be 2-3 times and for women range up to 11 times that for healthy persons.  It is important to remember, however, that maintaining cardiofitness from exercise must be a lifetime goal.  Its protection will diminish substantially starting a few weeks after exercise is stopped.

The actual risk relation formulas for various diseases vs. the CFR are noted following the appended table for those interested. Results from these formulas are now included in the Life Ahead program analyses. But as is a general policy in designing Life Ahead, minimum risks and a maximum benefit for each factor is taken at a level actually confirmed by available research data. Thus most benefits should be computed conservatively.

Diabetes and Family History:  Family history is an important and largely un-modifiable risk factor that can substantially increase the risk of suffering diabetes.  Type 1 diabetes that usually afflicts children appears mainly related to family history.  One study (Altobelli, E: Acta diabeto, 1998, 35:57) from Italy found a 4 fold increase in risk of Type 1 for any family connection, an 11 times higher risk if a father suffered it, and a 20 times higher risk if a brother suffered it.  Other studies of Type 1 usually found risks of 4 fold or higher for any family relationship.

But the far more frequent and potentially modifiable risk of Type 2 diabetes also is family history related.  Interestingly, the available research shows that family risk follow closely those of the general model for family risks developed for heart disease. This general model appears to apply approximately to family risks of all diseases studied.  This general pattern of family related risk of a disease that increases sharply with lower age-of-disease onset by the parent, that is higher if both parents had it than if one had it, and that is highest for the disease of a sibling follows:

Age of Family Member at First Disease    35      50      60      75 

Risk if one Parent had Disease          4.5     2.5     1.7     1.1

Risk if two Parents had Disease         7.1     3.9     2.6     1.8               

Risk if Sibling contracted Disease      9.7     5.3     3.6     2.0 

Only one study of diabetes reported risks that are usefully related to this profile (Meigs, JB, Diabetes, 49:2201).  This was the well known Framingham study that followed actual results obtained on parents and on their children over many years. This research found first descendant risks of 3.4 times for Type 2 of a mother, 3.5 times for diabetes of a father, and 6.1 times for diabetes of both. Disease by a mother that had age-of-onset below 50 had risk of 9.7 times; those having age-of onset above 50 had risk of 2.8 times.  Disease by a father below and above age 50 produced risks of 5.3 and 3.3 times respectively.  These risks closely pattern the risks of the above general model, but at a somewhat higher level.  Another study that followed risks for 22.5 years (Bjornholt, JV, Diabetes Care 2000, 23:1255) in Norway found risks of 2.51 for mother's disease, 1.4 for father's disease, and 3.96 for disease by both but ages of parent's onset were not given.  Most other studies reported a positive family relationship, but cited average risk values that were not useful relative to the above general model.  Note also the above finding of Altobelli that disease of a sibling produced a higher risk than that of a parent, as is shown in the general family risk model.

It is concluded that the general family risk model probably develops family related risks for Type 2 reasonably well, and this model produces risks that seem well within the error margin of the limited data available.  This valuation may be somewhat conservative vs the factors found by Meigs, but seems consistent with the balance of other data viewed.  And these risks for a family history of diabetes can become very serious.   Anyone now that does not have diabetes but had a parent or sibling that suffered diabetes - and especially if that member suffered the disease early - should be taking far more than usual steps to avoid contracting this most unwelcome life-diminishing disease. Any seriously overweight person that has a family history of the disease is unlikely to avoid contracting diabetes unless he or she makes serious lifestyle changes.  

Diabetes and Cigarette Smoking:  An individual of age 50 smoking a typical 30 cigarettes per day and starting smoking at age 17 develops about a 36% increase in risk of suffering diabetes. Life Ahead computes this risk for smoking that depends further on amounts smoked and age at which smoking is started. Risk as a ratio builds up with age to about age 50, and then levels off, declining somewhat  at older ages.  And risk declines toward zero ten years after smoking is stopped.  These are somewhat lower risks for smoking than are those for heart disease and most cancer. But smoking can multiply further the larger risks from other factors.

Diabetes and Blood Pressure: This is a very important factor that produces higher risk of suffering diabetes. The key research on this is provided in studies D1 and D2 in the table following.  Blood pressure also is an important factor determining risk of cardiovascular disease, and most deaths accompanying diabetes occur due to this cause. Thus it is useful to compare the risks for elevated blood pressure for coronary disease with those directly measured for diabetes.  This comparison follows:

                    Systolic Pressure Diabetes Risk Ratio Risk for Heart Disease

Study D1                 134               1.39              1.5       

                         149               1.96              2.1   

Study D2                 137               1.60              1.7                                 

                         152               3.6               2.3 

                         160+              5.6               3.4

The overall comparison suggests that the blood pressure risk for diabetes probably is at least equal to and perhaps even higher for diabetes that for coronary disease. The present Life Ahead program assumes in effect that the risk of diabetes for blood pressure will mirror that from coronary disease. This should provide a conservative valuation of this risk

Diabetes and Alcohol Intake:  Results of 6 available studies E1 through E6 in the Table below confirm that modest alcohol consumption will significantly reduce the risk of obtaining diabetes. This same finding is confirmed from results on dozens of studies on heart disease..  Interestingly, the average effect of alcohol in reducing risk of suffering diabetes is near exactly the same as for alcohol in reducing risk of heart disease for from  zero to about 10 drinks per week.  Risk for both heart disease and diabetes vs. no drinking declines to about 0.80 at 2 drinks per week; 0.67 at 4 drinks per week; and a minimum of 0.60 at 10 drinks per week.  Risks of  heart disease reverse and move back above above the risk for no drinks at 2.7 drinks per day;. Risk then expands to to more than twice the no-drink risk at 4.5 drinks per day. The limited data on diabetes suggest that up to 3 per day may not be harmful for this risk.  But a health-interested person must be concerned with the overall risk of drinking on risks of all involved diseases on length of life.  Because risk of cancer usually moves up steadily with amount of alcohol consumed,  the above cited web page shows that drinks of alcohol should be about 1 per day and not exceed about 10 per week for best overall benefit to health.

Diet and Diabetes:  Glycemic Index (GI) and Glycemic Load (GL):  Most research in diabetes has been involved with the very important and complex effects of diet. A key development here has been the Glycemic Index that measures the extent that a given food raises blood sugar. Most high GI foods are carbohydrates, but fiber that is classified as a carbohydrate has a minimal GI.  Thus the available carbohydrate for glycemic activity is taken as grams of carbohydrate minus grams of fiber.  To account for the amount of the available glycemic producing carbohydrate in a diet the GL is the product of GI times available carbohydrate divided by 100.

Studies F1 through F4 provide the key available research the relate values of the GI to risk of a diet to incidence of type 2 diabetes from very large studies.  Studies G1 through G4 provide similarly the results of GL and risks of diabetes from the very large studies.  Both measures appear to relate to diabetes risk in 3 of  4 of these studies.  (Study G2 involved a re-analysis of data from two of the other studies)  But not all research including that from some smaller studies found this expected relationship.  Most researchers prefer use of the GL as a more logical construct.  For most changes in diet, the effect of glycemic load is not large.  And as will follow, the GL does not predict well the effect of some diet nutrients as for example fiber and sugar.  Overall, an increase of about 70 in the GL is estimated to produce an increase in risk of diabetes of about 40%, or about a 0.6% increase in risk per unit increase in GL.

Study D2 of Dr Willet found a large 2.17 to 2.5 times risk for a combination of glycemic load and cereal fiber in diets of both men and women in the large studies. Surprisingly, the total amount of carbohydrate per se is not related to risk diabetes.  In fact both studies H3 and H4 below show risk of diabetes to be lower with larger amounts of total carbohydrate.  Thus only selected and specific high GI carbohydrates appear to produce diabetes.

Diabetes, Diet and Fiber:  Research studies I1 through I4 show consistently that dietary fiber reduces the risk of getting diabetes. Cereal fiber appears to be most effective, and fiber from fruits and vegetables was not effective.  The effect of total fiber probably supplies the most useful basis for individuals to use in estimating overall risk, and total fiber is used as the basis in Life Ahead.  These four studies suggest that an increase in total fiber from about 16 to 40 grams daily in diets involved reduce risk of suffering diabetes by 50%, or in about in half.  Curiously, a fact apparently overlooked by the researchers is that the computed effect of this fiber via the glycemic load method would be only 10% in a typical US diet.   Thus 4/5ths of the effect of fiber in diet must be due to either some other mechanism, or to a flaw in the construct of the glycemic load method. Because fiber is a non-digested component that often is assumed to move through the body without nutritive effect, this is quite surprising.  Life Ahead now adds the risk of the large actual residual contribution of fiber above that included in the glycemic load in computing the most probable true risk of diabetes.

Diabetes, Diet and Sugar:  Sugar long has been highlighted as the key villain that produces diabetes and increases its harm. Study K1 from the large Nurses Study shows at high significance that 1 + or perhaps about 2 sugar containing beverages taken daily will increase risk of getting diabetes by a substantial 87%. Fruit punch in similar amounts increased risk twice, at about 100%. It is of interest to compare this actual result with what would be expected from effect of these drinks on the glycemic load. 

As for fiber, the GL again failed to compute the probable risk of sugar in producing diabetes. Using a fairly typical US diet with included sugar containing beverages omitted, the addition of 2 sugar containing beverages per day at 7 teaspoons of sugar per drink would increase GL from 93 to 133.  Risks from the formula following the table that was derived from studies G1 though G3 would suggest an increase in risk of 22% for this change in GL. If we use 10 teaspoons of sugar equivalent for the soft drinks this still will show only a 30% change in risk This is only a third to a fourth of the actual measured risk of the sugar included in these drinks. Similarly, using actual GI and GL values for coca-cola, diet soft drinks, and fruit punch 2 drinks per day would compute an increased risk of only about 15%, again much below. the 87-100% actual increase in risk measured. . 

Table sugar is a combination of glucose and fructose with a typical glycemic index of about 70. Glucose by definition has a GI of 100, but the GI of fructose is quite low.  The relatively common level of 70 GI has misled some advisors to downplay the risk of sugar by citing that this modest GI is similar to that from many other common foods. The actual data on sugar containing beverages from this very large study confirms  the more historic view that sugar is indeed harmful, and should be avoided by health-interested persons. Today, with a wide and inexpensive choice of artificial sweeteners confirmed as healthful, much sugar intake can easily be avoided.

Life Ahead also includes for dietary sugar taken either directly or in sugar containing  beverages an additional risk vs. that computed by the GL to account for this substantial error. But candy and a vast number of other foods include varying content of sugar. Although we have no direct data on the diabetes risk from such other foods, it remains possible that the risk of all sugar containing foods may be undervalued by the GL.  Today's actual direct research confirms long standing advice that health-interested persons including those with and without diabetes should avoid excessive consumption of any food that contains substantial amounts of sugar. .

Diabetes, Diet, Whole and Refined Grains: Large study J1 confirms - as long has been advised  - that refined grains produce higher risk of diabetes than do whole grains. But it does not seem practical for individuals to identify quantitatively the whole and refined grain content of the various foods they eat, and  the GL that is included in Life Ahead may account at least approximately for this factor. The kinds of foods classed as whole and refined grains are noted following the results of this study.

Diabetes, Diet and Coffee:  Large studies L1 and L2 for men and women both confirm perhaps surprisingly that risk of diabetes risk is reduced for those that consume substantial amounts of coffee.  Results of a vast number of studies on coffee consumption vs. risks of other diseases have been far from convincing, and diabetes is just one perhaps lesser health problems related to this beverage. But it does appear that diabetics probably can consume much coffee without concern about this specific disease.

Diabetes, Diet and Magnesium:  Five mostly quite substantial studies M1 though M5 confirm a very consistent effect of magnesium in diets on risk of diabetes for both men and women.  The relationship derived is included in the formulas following the table of data.  Typical dietary magnesium values are about 275 to 325 mg per day. An increase from 250 mg to 500 mg reduces risk of diabetes by about 40%.  Magnesium also protects against heart attacks and strokes, and is a factor that every health-interested person should recognize. A desirable goal for magnesium for an average person is about 500 mg per day, an amount possible but unlikely from diet alone. This target appears appropriate for reducing risks of heart and other diseases with magnesium.  Most multi-vitamins include amounts of 25 to 100 mg, but supplements of 200 mg are inexpensive. Specific magnesium supplements of at least 100 mg or 200 mg may be needed for achievement of optimum magnesium in diet.  Life Ahead displays amounts of  magnesium included both in any entered diet and in dietary supplements used, and compares these values with targets adjusted for sex and body weight for each individual.

Other Factors Determining Risks of Suffering Diabetes:  The foregoing probably include the major risk factors for getting diabetes that mostly can be controlled by or should be of major concern to individuals. But other risk factors can be involved.  The risks of African Americans, Native Americans and Hispanics are significantly greater for diabetes than those of Caucasian Whites.  A problem in defining risks of such populations is that such groups also have differing lifestyles, and today this writer knows of no good way for assessing what portion of these risks could be due to these differing lifestyle risks.  Life Ahead now computes base risks for the recent US average population of non-smokers at the average lifestyle, diets, and other risks of this overall average population. The risks of this specific population are than valued for all changes in health modifying factors.

Cholesterol, HDL, and triglycerides have been identified as further risks for diabetes. Risks of these factors are extensively valued in Life Ahead.  A study suggested that Vitamin E might reduce risk by 31% (Montonen, J Diabetes Care 2004, 27:362) .  The effects of antioxidants on risk of diabetes have been conflicting, and a large study found no effect for beta-carotene.  Another study suggested that depression could increase risk (Golden, SH, Diabetes Care 2004, 27:429).  Two to four percent of pregnant women develop gestational diabetes during pregnancy that substantially increases their future risk of the disease during life; and women giving birth to babies weighing over 9 pounds may be at increased risk. These 'other' risks are not quantified adequately for inclusion in Life Ahead now, but health-interested individuals having such risks should be aware that their risks may be higher than those now calculated. And see the risks of cancer for those with diabetes that follow.

DIABETES and MAJOR RISKS

Diabetes Cardiovascular Risks:  The foregoing risks apply  mostly to those producing cardiovascular disease. How does diabetes develop cardiovascular risks?  Important clues are shown in the Global Analysis charts that have not have been recognized by most researchers.  Note how the time related risks of heart disease vs. diabetes intersect risks of about 1.6 for men and 2.3 for women and then move up steadily as the duration of diabetes increases.   This shows that diabetes risk clearly evolves from at least two quite independent mechanisms as a short term or near immediate effect plus an added long term progressive effect.  Short term risks could be due to increased blood clotting or some effect on artery plaque dislodgement.  The steady upward movement of risk with time of exposure to diabetes suggests an acceleration of the gradual progress of artery clogging of atherosclerosis that takes place during life. A likely cause here is the strong oxidative environment or oxidative stress produced by high blood glucose. An oxidative environment speeds up the atherosclerotic process that clogs arteries.  This highly oxidative environment could overcome the antioxidant effect of estrogen that helps protect women before the menopause and thus explain the difference in risks diabetes on of cardiovascular disease for men and women.

Diabetes and Cancer:  More than 50 studies relating diabetes to cancer risk appear in a Medline search. These show that diabetes does affect the risk of some types of cancer.  Five good studies and a meta analysis show interestingly that the presence of diabetes reduces risk of prostate cancer. The average of the 5 quite large studies that includes that of the US health professionals suggests a an average risk factor of 0.65, or a 35% lower risk.  The meta analysis that included mostly smaller studies found a lesser but significant reduction in risk of 0.91 (limits 0.85-0.96).  As a compromise, Life Ahead accepts a factor of 0.8, or a 20% reduction in risk of prostate cancer for those with diabetes.

But diabetes increases risk of cancer - and can increase this risk quite substantially - at other sites.  Four good studies of diabetes and colorectal cancer including that of the large Nurses study  confirm an average increase in risk of 1.37 or 37% for both men and women.  Five studies each confirm a very substantial effect of diabetes on risk of women's endometrial cancer averaging 2.9 times. Two of three studies suggest a doubling of diabetic's risk for pancreatic cancer and a 2.5 times risk of liver cancer. Studies of lung cancer and ovary cancer found no effect of diabetes.

HEALTH VALUATION of DIABETES RISK in LIFE AHEAD

The the results of the above research on the risks of obtaining diabetes is not included in Life Ahead Version 2, but will be included in Life Ahead Version 3 now being developed.  Version 2 does include the important effect of those having diabetes on the risk of cardiovascular diseases. Version 3 will include as one of many new enhancements an individuals' risk of obtaining diabetes from lifestyle, and the more extensive consequences of this risk on on Well-Days of healthful life. Most risks and values described here are for Type 2 diabetes that comprise 90-95% of the disease's events, and that mostly occur after ages 20-30. This paper is being provided in advance because it shows health-interested people their risks of getting diabetes and how they can be modified. You can obtain a estimate of your risk of diabetes at age from the first above table relating risk to age and body weight. Then multiply this risk by how some of your other risk factors described compare with those for a usual population.  Most of those with a family history of the disease who are even modestly overweight will have a very high risk of obtaining it.   

Life Ahead Version #3 first identifies an individual's risk of obtaining diabetes, and second, the risks of premature death of those that already have or are likely to obtain the disease at identified future ages. The program first values a risk of obtaining diabetes as a product of the risks of all previous factors described above. As always in Life Ahead, all risks are valued relative to a value of 1.0 for the average US population using a typical US diet.  Most of the actual formulas used are appended here following the tables of the actual research results. As shown above, risks of diabetes can vary from a fraction of this average to fifteen times this average for combinations of present population risks and lifestyles. The risks of getting diabetes for many people will be far higher than their risks for heart disease, cancer, or any other major health risk.

The risks of death for the fraction of the population not now having diabetes that will be expected to have the disease at age are divided into two parts:  First are their higher risk of the cardiovascular (CVD) diseases of heart attacks and strokes.  Most of these added risks for diabetics probably display in recent NIH health statistics as 'cardiovascular diseases'.  Second are their risks of death from factors that are shown in NIH statistics as 'diabetes' and that now are not well defined.  Life Ahead first identifies the percent of population having diabetes risk adjusted as just noted above for risk factors as a percent of the total remaining population at each age of life starting at age 20. This fraction that is small at early ages is then valued for added CVD risk as per the formulas for diabetic men and women following the Research Tables and as shown graphically on this website. At each successive year of life the CVD risk of this population fraction will increase with duration of the disease from its year of origination.  Life Ahead maintains for each year of life and for every combination of user habits and other risks the total fraction of the population likely to have diabetes at each age and its average age of onset. This should permit valuation of this risk at each future age of life to life expectancy.  No further increase in risk is computed for diabetes duration values of more than 30 years, the maximum time actually now actually valued by research. 

An individual that has already contracted diabetes at a specific age will have risk valued directly from the appended formulas after this age of diagnosis is reached.  Most individuals with Type 1 diabetes will have experienced it before age 20, and if these facts have been registered in Life Ahead these individuals will be substantially valued for their added risk of CVD. Deaths from diabetes due to CVD disease are added to the overall segments of those suffering heart disease and stroke. Deaths shown in the category of 'Diabetes' are taken as in their usual fraction of deaths from the disease each year times the computed extent of diabetes vs average.

Life Ahead Version #3 recognizes cancer risks of 0.8 for prostate cancer, 1.37 for colorectal cancer, and 2.9 times for endometrial cancer starting at the date of diabetes onset. These risks are applied directly to those that enter diabetes as a current disease, and for others, the fraction of the population estimated to have diabetes from known risks at age. The effect of increased risks of pancreatic and liver cancer are not segregated in the program now but are recognized as parts of the 'other' cancer group.

The foregoing risks for CVD from diabetics will be included in the Life Ahead disease risks for heart disease and stroke to reflect values provided in the US vital statistics.  The remaining risks to be recognized as 'diabetes' per se for death rates are now identified as directly proportional to the risk ratio of extent of diabetes risks to that for the average US population. This may be a somewhat conservative basis, but most major risks as for diet, cardiofitness, weight, etc are involved in the extent of diabetes per se, and probably should not be increased further. All of the risks of diabetes are reflected directly in computations of Life Expectancy and Well-Days of life.  This sophisticated valuation of a diabetes risk used in Life Ahead Version #3 requires tens of thousands of computations for a valuation that would be impractical without the availability of today's very fast computers. No comparable valuation either of risks of diabetes per se or of overall risk of death from this disease has been found published elsewhere.

 THE MAJOR RESEARCH on DIABETES RISK FOUND PUBLISHED

Understanding the Research:  The tables following provide most or all of the important useful research in on risks related to risk of diabetes on populations found published to latest date listed. Most researchers and health writers base their ideas on just a few or even just one most recent study because it can take many months of time to produce the more complete reviews provided in Life Ahead, and in depth analyses of this type usually have not been available.   But these comprehensive listings are an essential need to obtain a most up-to-date and correct answer to a factor risk.  The important finding of research is the risk ratio, or the risk of disease of those with a better health factor vs. those with a base or usually average or poorest health factor.  A risk ratio of 0.5 means risk of those with better health factor have half the risk of those with the poorer one.  A ratio of 0.25 means they have only 1/4th the risk; a ratio above 1.0 means a negative result from the factor.  Occasionally, a risk is expressed in reverse as a harmful factor as for the effect of BMI or weight and glycemic indexes on risk diabetes that follows for studies A1 and A3. These higher  risks will then show as values above 1.00

Look down at the risk ratios found.  If risks from most or all studies show values lower than 1.0 (The BMI and Glycemic values will be higher than 1.0 as they are shown as reverse factors) you can be assured that the effect being measured is of good significance. The fact that some studies do not reach 95% significance individually can be meaningless. If most of several or more studies have risks differ consistently and significantly from 1.00 a truth may be established at levels of above thousands to one.  Some studies include 3, 4 or 5 results at differing "dose" or amounts of factor levels.  If these show steadily declining ratios with dose, significance becomes enhanced.  Some studies show "p" ratios of significance.  A p value of 0.05 or denotes that a factor is confirmed with 95% probability.  A lower p value of say 0.01 is 99% and a p of 0.001 can define significance at a thousand to one.

Most health research has high margins of error. This fact rarely is communicated to the public.  Because of these error margins, it is necessary to have results of multiple studies to assure a probable truth. The risk ratios herein thus are followed by an error margin, as limits of 5% to 95% probability.  If a ratio is 0.75, and the limits are 0.5 to 0.9, the study really produces only a likely result of a risk lying somewhere between 0.5 and 0.9.  The usually quoted risk of 0.75 is not accurate. But because the upper limit is still below the null value of 1.00 this result usually will qualify in the study publicity as "Statistically Significant"  If the error margin is say 0.4 to 1.15, and the upper level is above 1.00, the individual study usually will be "Not significant."  Researchers sometimes say incorrectly that "We found no effect" when a value is "Not 95% significant"   The produces Statistical Confusion that can be very misleading.  Two studies, each finding a risk of 0.75, and each with say error margins individually of 0.45 to 1.10 can define in combination a significant result even though each individually did not include sufficient data to reach significance. A best answer thus is revealed by what ALL of the useful RESEARCH shows in combination.   This is what the tables following attempt to find. 

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