How Sweet It Isn't

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Since 2015, the Florida Diabetes Advisory Council has issued an annual report on diabetes and its impact on the state. A key finding from the panel’s 2023 report: More than 2.7 million Floridians — about 11.8% of the population — have diabetes. That’s more than double the percentage of Floridians affected by diabetes in 1995.

Diabetes-related health complications can include kidney failure, lower-limb amputations and blindness. People with diabetes also are more likely to develop heart disease or suffer a stroke and are two to four times more likely to die from a cardiovascular cause, according to studies. In 2020, there were 7,516 deaths in Florida with diabetes listed as the underlying cause.

Beyond the health toll is a financial one. The medical expenses of a person with diabetes are more than two times higher than for individuals without diabetes, according to the American Diabetes Association. The organization estimates that people with diabetes incur nearly $16,800 per year in medical expenditures — with nearly 57% of that tab directly attributed to diabetes.

In 2017, the total cost of diabetes in Florida was approximately $25 billion, according to the Florida Diabetes Advisory Council. The bulk ($19.3 billion) is attributed to direct medical expenses for diagnosed and undiagnosed diabetes, prediabetes and gestational diabetes, with the remaining $5.5 billion attributed to indirect costs.

For this special report, Florida Trend checked in with diabetes experts from around the state to learn more about what they’re seeing and how they’re helping patients tackle one of today’s biggest health challenges.

Not Just an Adult Disease

Type 2 diabetes in children is on the rise. It’s tougher to treat in youngsters and portends poorer outcomes, but new treatment options may help them better manage the chronic disease.

Types 2 diabetes is not the most common form of diabetes in children, but it is on the rise. Twenty-two years ago — when Type 2 diabetes was often referred to as adult-onset diabetes — doctors were seeing 0.3 to 0.4 cases per 1,000 kids. Today, the prevalence in youngsters has doubled to about 0.7 cases per 1,000.

Doctors say the trend is concerning because it’s a more challenging disease to treat in kids than in adults.

Like adults with the disease, children who have Type 2 diabetes are encouraged to restrict their intake of sugar and carbohydrates and increase physical activity. Along with medications, such as insulin and metformin, children may begin to produce enough insulin on their own to eventually come off some of the treatments — but the disease can be stubborn.

“Often, adults actually improve with treatment, but we don’t always see that in children,” says Matthew Benson, a pediatric endocrinologist and medical director of the diabetes program at Nemours Children’s Health in Jacksonville. And the failure rates among children treated with a single medication such as metformin also are “much higher” compared to adults, he says.

Though the reasons aren’t entirely clear, studies suggest a contributing factor may be the high level of insulin resistance that children develop during puberty.

Insulin, a hormone produced by the pancreas, works similarly to a key in a lock. It binds tightly with receptors on the surface of cells, opening them so that they can absorb sugar from the blood. When insulin resistance occurs, however, the key no longer opens that lock as easily and blood sugar levels rise. While all children develop some insulin resistance during puberty, it usually returns to normal when puberty is complete. That isn’t the case, however, among youth who are obese.

Youngsters with Type 2 diabetes face a high risk of complications. A 2017 study funded by the National Institutes of Health and the Centers for Disease Control and Prevention followed 272 young people with Type 2 diabetes for 13 years. By the end of study, nearly 20% of the youth had developed a sign of kidney disease, 18% had developed nerve disease and 9% had developed eye disease.

“With Type 2, the outcomes are poor. They a have higher rates of retinopathy (damage to blood vessels in the eye), they have higher rates of nephropathy (kidney damage),” says Benson. “Huge numbers of them are already having significant eye problems by their mid-20s. Similarly for Type 1, only 20% or so of children get their diabetes in range so it’s a really big problem, and it’s a very expensive disease as well. Diabetes is very costly.”

The good news amid all the bad, Benson says, is the growing list of pharmacological treatments.

For many years, the mainstay of treatment for Type 2 diabetes consisted of just two drugs — insulin and metformin, an oral medication that suppresses how much glucose your liver makes. Today, some pediatric patients have more options, including injectable GLP-1 agonists — which are also popular weight-loss drugs — and oral SGLT2 inhibitors, which cause the kidneys to excrete more glucose.

Insulin pump technologies, meanwhile, are revolutionizing the management of both Type 1 and Type 2 diabetes in kids, Benson says. The devices work almost like an artificial pancreas by continuously monitoring blood glucose levels, and based on that data, release the amount of insulin the body needs to keep glucose levels in a tight range.

Benson also is encouraged by strides being made in the treatment and prevention of Type 1 diabetes, which historically has accounted for about 90% of the cases of diabetes in children.

Type 1 diabetes occurs when the immune system attacks and destroys the pancreatic cells that produce insulin. The disease progresses through two asymptomatic stages — from stage 1, when antibodies begin attacking the insulin-producing cells, to stage 2, when blood glucose levels become abnormal. It culminates in diagnosis at stage 3, when the patient presents with an array of symptoms including excessive hunger or thirst, frequent urination, unexplained weight loss, fatigue and blurry vision. Unlike Type 2 diabetes, Type 1 will not improve with dietary changes and exercise and requires insulin.

In 2021, the U.S. Food and Drug Administration approved teplizumab, a biologic injection that can delay the onset of stage 3 Type 1 diabetes for up to three years. The drug, which is given through an IV once a day for 14 straight days, appears to work by deactivating the immune cells that are attacking the insulin-producing cells.

Benson believes it will be a game-changer, especially if children are screened at regular intervals for the antibodies associated with Type 1.

“We have never seen anything in the Type 1 space that was a disease-modifying therapy,” Benson says. “The hope is we can start to delay the age of diagnosis of Type 1 diabetes and then potentially combine that with other therapies to push the age of diagnosis to an older age.” — By Amy Keller

The Burden in Children

• 18,300: number of newly diagnosed cases of Type 1 diabetes in Americans under the age of 20 each year
• 5,800: number of newly diagnosed Type 2 diabetes cases in Americans under the age of 20 each year

Diabetes During Pregnancy

Gestational diabetes mellitus (GDM) is a form of high blood sugar that can develop in pregnant women who don’t already have diabetes. It affects up to one in 10 pregnancies, according to the American Diabetes Association. Kim Rohrbacher is a registered nurse, a certified diabetes care and education specialist, and Tallahassee Memorial HealthCare’s assistant nurse manager of endocrinology, obesity and diabetes. She spoke with Florida Trend about GDM.

TRENDS: We’re seeing an uptick in GDM in pregnant women. A recent study revealed that GDM increases with the increasing age of the mother. For example, pregnant women under the age of 20 typically only had a 2.5% rate of GDM, whereas with mothers who were age 40 and older, the rate was 15.3%. Maternal age is a factor, but a family history of Type 2 diabetes is also a contributing factor to GDM.

SYMPTOMS: One of the interesting aspects of GDM is there are no real symptoms in the mother.

RISK FACTORS: Ethnically, Asian and African- American women are at an increased risk of developing GDM.

A HARBINGER: There are a lot of misconceptions about GDM — that it is only a problem during the pregnancy, and really nothing to worry about afterward. That really couldn’t be farther from the truth. Women who have gestational diabetes are greatly at risk for developing Type 2 diabetes about 5 to 10 years after their pregnancy.

IMPACT: Excess sugars in the mother during pregnancy can lead to the birth of a large baby, and more than 9 pounds is considered large. Studies have shown that large babies born to mothers with GDM have a greater chance of becoming obese during adolescence and into adulthood.

TREATMENT: The gold standard for treating GDM is insulin. When the mother delivers the baby, they won’t have to take insulin anymore.

SCREENING AND CARE: Here in Tallahassee, the obstetricians do a great job screening for GDM and referring their patients for appropriate care. We have a weekly class here at TMH that is filled every week with women who have GDM. The first step is to teach them the appropriate things to eat and how to manage their diet and add in some light physical activity. Then we follow them very closely, usually every week we review their blood sugar logs and their food records.

RURAL DISPARITIES: I will say that within our (service) area, the town of Quincy has one of the highest rates of diabetes, and so we do see a lot of women from that largely rural area diagnosed with GDM. TMH also offers a family residency program which sends obstetricians out to rural clinics to provide care as well as educational programs through our telemedicine network. — By Carlton Proctor

• Tracking Moms

Data from the Pregnancy Risk Assessment Monitoring System, a surveillance project of the Centers for Disease Control and Prevention and health departments, found that 12.1% of recent mothers in Florida in 2015 reported having gestational diabetes during their most recent pregnancy. The same year, 1.8 % of recent mothers in Florida reported having pre-existing diabetes before their most recent pregnancy.

The Prediabetes Epidemic

Nearly 36% of adults in Florida have prediabetes, the precursor to Type 2 diabetes, according to the American Diabetes Association, but most people who have it aren’t aware, says Doris E. Smith, an adult/gerontology primary care nurse practitioner for UF Health Jacksonville.

Fifty percent of those with prediabetes will go on to develop Type 2 diabetes in the next five to 10 years, according to the Cleveland Clinic.

The risk for prediabetes and diabetes increases for those over age 45, overweight or obese, and those who have parents with diabetes, among other risk factors. The risk for prediabetes is also higher for patients of color.

Although prediabetes may have symptoms such as increased thirst or hunger, frequent urination and blurred vision, many people are asymptomatic, says Joshua Neal, a family medicine doctor with Ascension St. Vincent’s in Jacksonville. “Normally, we pick it up through labs, either with a fasting glucose or hemoglobin A1C,” he explains. Hemoglobin A1C checks how much blood sugar is attached to each red blood cell and provides an average over three months: A level of 5.7% to 6.4% indicates prediabetes.

The key recommendation that Neal shares with most prediabetes patients is to lose 5% to 10% of their body weight. “Typically, this amount of weight loss will lead to a resolution of their prediabetes,” he says. This can be challenging, he says, as bodies tend to have natural mechanisms to fight weight loss. Medication and sometimes bariatric surgery are options.

A diet with fewer refined carbohydrates, more physical activity and smoking cessation also can cut the risk of prediabetes developing into Type 2 diabetes, Smith says. Once prediabetes is identified, clinicians will monitor labs every three months, Smith says.

Annual screening should be done for those with prediabetes risk factors, such as obesity, a sedentary lifestyle, a family history of diabetes or previous gestational diabetes, and for those with cardiovascular disease, Neal advises.— By Vanessa Caceres

Back from the Brink

A West Palm Beach endocrinologist is skeptical about findings in a recent study about prediabetes posted by the Journal of the American Medical Association.

The study concluded that without an exercise regimen, people with prediabetes see no reduced risk of death when they revert to having normal blood sugar levels.

While the exercise can only help, Eliud Sifonte, an endocrinologist at NYU Langone Medical Associates outlets in West Palm Beach and Delray Beach, says the very act of avoiding a full diabetes diagnosis “will definitely lead to a decrease in mortality risk.”

Prediabetes, the study says, can increase the risks of cardiovascular disease, chronic kidney disease, cancer, dementia and death. Most patients with prediabetes feel no symptoms and learn about it through blood tests.

But many can gain control over those blood sugar counts through diet and exercise, which, Sifonte says, should reduce that risk of dying.

The study published last spring was based on one fasting blood glucose sample, which could have inflated the number of people classified as having prediabetes, he says. Lab errors may have further skewed the data. “We always like to repeat the test to confirm before diagnosing a patient with dysglycemia,” or abnormal blood sugar levels.

Sifonte suggests his patients lose some weight, shift to low-fat, low-carb diets and exercise at least 150 minutes each week.

And the doctor cautions against drawing conclusions based on the study. “It is an interesting finding but leaves some questions up in the air,” Sifonte says. “We view dysglycemia as part of a more complex metabolic disorder.” — By Michael Fechter

Tags: Feature, Diabetes, Health Care