Diabetes Prevention in Dermatology
Are you at risk for diabetes? You may be: many people at higher risk for diabetes have no idea. In fact, the latest statistics indicate that 90% of people with prediabetes don't know that they have it. And that can be a serious problem, because the health effects of diabetes and prediabetes can be so serious.
Let me tell you about one of my friends. She looks (and feels) in great shape: she works out, she's thin, and to look at her she's the picture of health. She was surprised, then, that her doctor ordered a blood test for diabetes when she turned 45.
She was even more surprised when the test showed that she had prediabetes. (She's the picture of health! She feels great! She has no symptoms!)
The thing is, she IS at higher risk. Age over 45 is one of the major risk factors for diabetes. She also has one parent with diabetes, and she has mild psoriasis, both of which are additional risk factors. Getting this diagnosis was a huge wake-up call for her: as healthy as she was, she still needed to make some changes. She was already exercising on a regular basis, but her meals could be better. She wasn’t overweight, but the foods that she was eating on a regular basis weren’t as powerful as they could be. She turned her focus to really increasing her intake of fiber, especially via fruits and vegetables, instead of eating processed carbohydrates.
And it worked. When she went back six months later, her blood test showed that she was back in the normal range. Let’s walk through why somebody like my friend would be at higher risk for diabetes, and, importantly, what can be done to reduce your own risk.
Why is diabetes prevention so important?
There's currently a diabetes epidemic raging through the United States.
We may not hear about it frequently, but it affects many of us. In fact, the latest data indicates that close to 10% of the United States population is afflicted with diabetes. And an estimated one out of every three Americans has prediabetes.
Why is this high rate of diabetes and prediabetes so important?
You may know a lot of people with diabetes. And you may start to think of it as not so concerning. But the fact is, despite the great advances in diabetes treatment that have been made, there are still a lot of complications and health effects of diabetes.
Although good medical treatment and lifestyle changes can greatly reduce the risk of complications, the fact remains that diabetes puts an individual at a much higher risk of health complications.
In the time of COVID, this is especially urgent, as patients with diabetes have a higher risk of developing more severe outcomes from COVID. Even without COVID, it’s well-known that diabetes increases the risk of heart disease and heart attacks, as well as vision complications, kidney disease, and even multiple skin problems.
What can diabetes do to your skin?
The reason why dermatologists are so familiar with diabetes is because it has a number of different impacts on the skin:
Impaired wound healing: It has been well documented that when patients with diabetes have a cut or scrape, it can take longer for their skin to heal.
Higher risk of foot ulcers and non-healing sores: This is due in part to the effects of higher blood sugar levels on tiny blood vessels that supply the skin. It is also due in part to the effects of blood sugar levels on collagen.
Damaged collagen: High blood sugar levels start to damage collagen which can accelerate wrinkling and sagging of the skin over time. This process is commonly known as sugar sag.
You may know your cholesterol, but do you know your hemoglobin A1C level?
When I turned 45, my primary care physician ordered a blood test called a hemoglobin A1C level.
This single blood test alone can actually diagnose diabetes or prediabetes. It measures the average of your blood sugar levels over the previous three months. You don’t even have to fast to take this test.
If you have a hemoglobin A1C level of 6.5 or above, you would be diagnosed with diabetes. If your level is between 5.7 and 6.4, you would be diagnosed with prediabetes.
Who should be checked for diabetes?
It used to be that everybody knew their cholesterol number. Now, everybody needs to know their hemoglobin A1C level. Or at least, everybody over the age of 45.
The American Diabetes Association (ADA) recommends that everybody over the age of 45 gets their hemoglobin A1C level checked every three years.
If you are overweight, you may need to have your level checked at an earlier age. The ADA recommends that anybody who is overweight and is non-Caucasian have their lab checked.
If you do not exercise, or have a family history of diabetes, or have high blood pressure, you should also have your levels checked at an earlier age.
The bottom line: if you are overweight, you should check with your primary care physician about which labs are needed.
What do you mean by overweight?
The medical definition of overweight is a BMI of 25 or higher. For a woman who is five foot five, that equals a weight of 150 lbs.
Note that if you are of Asian heritage, you are considered at higher risk if your BMI is 23 or higher.
There are many free BMI calculators online. To calculate your BMI, you only need to know your height and weight.
Who else should have their blood levels checked?
We know that patients with psoriasis are at higher risk of diabetes. In fact, one study spanned over 13 years and examined over 50,000 patients with psoriasis. What they found was that these patients had a significantly increased risk of new-onset diabetes. In another study, this risk was found to be higher the more severe the psoriasis was.
What this means for my patients with psoriasis is that it is important for them to know that they are at higher risk for developing diabetes. While this risk is higher if they are overweight, the risk is also higher for patients who are at a normal weight.
What other dermatology patients might be at risk?
I consider checking for diabetes in patients with:
frequent yeast infections of the skin
hidradenitis suppurativa (HS): Patients with HS who do not have the traditional risk factors for diabetes (such as age and being overweight) are still at higher risk for diabetes.
polycystic ovarian syndrome (PCOS)
Dermatologists may see PCOS patients because they will sometimes develop acne, hair loss, or extra hair growth. Studies have found that patients with PCOS have a higher risk of diabetes. For example, one study found that 40% of patients with PCOS had diabetes, as compared to 6% in the general population of a similar age. Another study found that patients with PCOS who were at a normal weight still had a three-fold increase in their risk of developing diabetes as compared to normal-weight women without PCOS.
What do you do if you're diagnosed with diabetes?
The most important next step is to see your primary care physician. There are wonderful diabetes education programs that can help you learn the right lifestyle changes to help reduce your risk of complications, as well as learn how to take your medication correctly.
In some cases, diabetes can even be reversed with the right lifestyle changes, although that should never keep you from immediately starting medical treatments.
What if I've been diagnosed with prediabetes?
We talk a lot about the early detection of diabetes. Making an early diagnosis of diabetes is important because starting treatment immediately can limit your risk of severe medical complications.
The early detection of prediabetes is also incredibly important. That’s because diabetes prevention begins with detecting prediabetes.
Let me repeat that! Diabetes prevention begins with identifying individuals with prediabetes. While these individuals are at higher risk for diabetes, the right changes can prevent it.
What is prediabetes? It’s an intermediate state. Your blood sugar levels aren’t high enough for you to be diagnosed with diabetes--but if you don’t modify several lifestyle factors, you have a higher risk of developing diabetes.
Can prediabetes be reversed?
Absolutely. The reason we are so focused on diagnosing prediabetes is because it can absolutely be reversed.
Research studies have found that lifestyle changes can make a big difference. In fact, a structured diabetes prevention program has been shown to reduce the risk of diabetes by 40% to 70% in adults with prediabetes.
On the other hand, without lifestyle changes, it’s estimated that about 20% of people with prediabetes will develop diabetes annually. By making lifestyle changes, you can cut that risk dramatically.
Lifestyle changes can reverse prediabetes.
Changes in nutrition and exercise habits can make a dramatic improvement in your blood sugar levels. But we know that changing lifestyle habits can be challenging to start and to sustain. That’s why it helps to have a group and a coach to help you with these lifestyle changes.
Dietary changes to help limit blood sugar spikes.
The dietary recommendations that we’ve all heard as good for our health apply here. Focus on whole foods. Eat more fruits and vegetables. Eat more foods that are naturally high in fiber. Why? Because a diet based on whole and less processed foods naturally acts to stabilize blood sugar levels.
When you eat a chocolate frosted cupcake, you're consuming a hefty dose of refined carbohydrates and a hefty dose of added sugars. Your body digests that type of food quickly and that sugar is quickly absorbed into your bloodstream. That's what we call a sugar spike. Enough of those sugar spikes over time will significantly up your risk of diabetes.
To avoid those rapid spikes in your blood sugar levels, you need to watch out for added sugar and refined carbohydrates.
Is there anything that you can eat to slow down the release of blood sugar into your bloodstream? Yes. Fiber is one of the main nutrients that helps to stabilize blood sugar levels. The high fiber content of many fruits is the reason why the sugar in whole fruits is absorbed at a more stable rate into the bloodstream. Meals with a dose of protein and/or fat also help to slow down the release of glucose.
Certified diabetes prevention programs can help.
The CDC (Centers for Disease Control) has a list of certified diabetes prevention programs. We call these DPPs.
If you are a Medicare patient and have prediabetes, then you can enroll in these programs and Medicare will cover the cost. Other health insurance plans or employers may also cover the cost.
What do these programs cover?
DPPs are small group programs that meet 22 to 24 times over the course of a year. They are led by certified lifestyle change coaches who work with patients to help them make long lasting sustainable changes.
The goal of a DPP program is to also help you achieve weight loss. In order to be certified, programs must help their participants reach weight loss goals of 5% to 7% of their body weight.
For a woman who begins at a weight of 150 pounds, the goal would be to lose about 8-10 pounds. That amount of weight loss would be enough to significantly reduce her risk of developing diabetes.
A research study found that participation in a certified diabetes prevention program helps reduce the risk of diabetes by about 50%.
Who offers these programs?
The CDC maintains a list of certified DPPs. It’s important to know that these programs are not administered by the CDC. Instead, they are run by local organizations or healthcare providers.
For example, in Houston there are programs offered by the YMCA. Nationally, there are also telehealth programs that are administered remotely.
What if my insurance doesn't cover the cost of this program?
If you have prediabetes, it is worth checking with your insurance company to see if they cover the cost of a certified DPP.
If not, the AMA has estimated that programs cost about $400-$500 for a one-year program.
I checked with one program at the YMCA, and the cost of the program was $30 per month. That cost even included membership to the gym at the YMCA.
The Bottom Line: If you are in a high-risk category, you need to know your hemoglobin A1C level.
High-risk categories include:
o Patients who are 45 or older, of any weight
o Overweight patients of any age who have additional risk factors, such as
being non-Caucasian, having a family history of diabetes, or having a
If your A1C level is 6.5 or above, then you need to seek immediate treatment for diabetes
If your A1C level is 5.7 to 6.4, then you would be diagnosed with prediabetes.
o This state can be reversed! You might consider certified diabetes prevention
programs to help you lose weight and reduce your risk of progression to
diabetes. These programs can reduce that risk of diabetes by about 50% and
take place over the course of a year.
Diabetes Prevention Programs: If you are interested in certified diabetes prevention programs, please refer to this registry of CDC certified programs: https://nccd.cdc.gov/DDT_DPRP/Registry.aspx