Derailing the 'Inevitable' Onset of Diabetes

Identifying Risk for Disease, Well Before It May Occur

Lieutenant governors often do not have a lot to do. They might be a little busier than a Maytag® repairman at times, but for the most part, they wait for the governor to become incapacitated or accept an assignment from the governor.

Richard M. Plotzker, MD

A number of years back, the sitting governor of Delaware assigned her understudy to chair a state cancer commission, whose principal project was to provide colonoscopies to residents of the state. The project went rather well.

Later, at a state medical society meeting, the lieutenant governor presented data and lessons from the project. He noted that the best single predictor of dying of colon cancer was not family history, but failure to finish high school.

After that session, while he and I were wandering around the convention's exhibits, I asked him whether the state had a mechanism to use those health data—which it has for other diseases, including diabetes—to promote disease reduction by investing in education (which is also under control of the state). He indicated no formal connection in the state's agenda between the parallel goals of educational effectiveness and citizen health. And, to the best of my knowledge, none exists in other states either, despite ample data linking educational attainment to certain diseases.

If failure to finish high school serves as a marker for something that's likely to happen decades later, can that information be used to screen people and intercept those diseases in their most manageable stages?

A few years ago, the Endocrine Society dedicated the theme of its annual meeting to disparities in outcomes of various endocrine disorders. Diabetes seems to cause more end-organ damage in African American persons and people with lesser economic resources, and some thyroid disorders and osteoporosis also stratify along ethnic lines.

These disparities have been documented in people who already have these diseases, but what about people who do not have the disease yet but are at high risk? How far in advance can we identify and track these people? If failure to finish high school serves as a marker for something that's likely to happen decades later, can that information be used to screen people and intercept those diseases while still in their most manageable stages?

Educational Level and Risk for Type 2 Diabetes

An intriguing review by Steele and colleagues^[1] recently appeared in BMJ Open, which looked at data from a large population base and prospectively tracked the likelihood of people aged 50-75 years acquiring diabetes over an 8-year interval.

This study focused on a single state within Germany and extracted data from more than 7000 individuals who did not have diabetes at the beginning of the study. The investigators found that formal educational attainment would stratify the likelihood of developing diabetes in a person's later years, perhaps with a "heads up" of some 40 years.

As Americans, we view our population as a mosaic of genetics, whereas educational attainment or economic sufficiency are compartmentalized differently across various ethnic groups and other subpopulations. The German study has the advantage of being able to look at educational level without that confounder.

Americans also tend to divide education levels as less than a high school diploma, completion of high school, some college, and a college degree. In this study, the gradations were low education (9 years or less), medium education (10-12 years), and high school graduation or above (the top educational level).

Another distinction is that Germany has a national health system, with its origins dating to the time of Otto von Bismarck, so access to medical care is less of a contributor to disparity than in America. Even with what seems like an optimal circumstance to engage in ongoing prevention of serious diseases, the people in the study who acquired type 2 diabetes within the 8 years of observation still were stratified by educational category.

The authors made the assumption that limited educational attainment does not occur in isolation, but rather with less income and perhaps more hazardous occupations.

They tried to ascertain whether more traditional risk factors for diabetes also clustered with the educational levels. Their data showed that people in the less educated groups were heavier, had stronger family histories of diabetes, exercised a lot less, took fewer nutritional supplements, and ate fewer vegetables—suggesting that they were less focused on their health than were their more affluent countrymen.

People in the lower education group also had more hypertension, although much of it was treated. And, as might be expected in a heavier group, more people were hypertensive and had higher values of triglycerides and C-reactive protein.

Alcohol consumption, on the other hand, was significantly higher in the cohort with more formal schooling, although the number of problem drinkers was a minuscule fraction of all participants.

The likelihood of developing diabetes correlated with traditional risk factors whatever the educational level happened to be, although these risk factors were disproportionately prevalent among the less educated people.

The best thing you still can do for diabetes is to keep people from getting it.

As those of us who treat diabetes in America and worldwide well know, public policy attempts to reduce the prevalence of diabetes have been an utter failure, with a worldwide pandemic in progress. To be fair, part of the rising prevalence is the fact that people are being treated more effectively and are living longer with the disease. But regardless of advances in diabetes care, the best thing you still can do for diabetes is to keep people from getting it.

It's probably difficult to change public policy even if you know far in advance how diabetes will be distributed decades after the high school diplomas are handed out, but the authors make some important observations that might be generally applicable. Many studies of diabetes rely on patient self-reporting. The reality is that there are a lot of undiagnosed cases that will not be identified until those people get sick. The German researchers used lab tests and medicine prescriptions to identify people with diabetes.

Universal testing of the entire population at periodic intervals would be a helpful and realistic intervention. Identifying individuals who would benefit from weight control or diet modification also seems realistic.

So, although the study suggests that your destiny may be determined by your 11th-grade guidance counselor, you still have 40 years beyond that to try to make the onset of diabetes less than inevitable.

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