Type 2 Diabetes And Pre Diabetes Biology Essay

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Type 2 Diabetes is one major causes of death in the United States today. T2D is characterized by the bodys ability to manage and tolerate glucose levels. To measure a person's glucose tolerance, people are asked fast overnight before they are tested for the Fasting Plasma Glucose Test. Blood glucose metabolism is determined by the rate of glucose appearance and disappearance from both the liver and to a small extent the kidney (13).

The disease usually proceeded by insulin resistance, progressing to pre-diabetes and eventually the state of diabetes. There are many factors that could be contributing to the development of diabetes, and the two that have been mentioned the most are a lack of physical activity and unhealthy eating habits (1, 2, 3, 11, 15). The Centers for Disease Control and Prevention (CDC, 2008) has estimated that that 8% of the US population or about 24 million Americans are living with diabetes. Another 57 million people are estimated to have pre-diabetes and the total prevalence continues to increase (CDC, 2008). Along insulin resistance, T2 D is said to be caused by genetic, environmental factors and β-cell dysfunction (3). By the year 2004 there were 1.3 million new cases of diabetes occurring annually in the United States, and in 2007 this had risen to 1.6 million (4). It is well known that individuals with Type 2 Diabetes develop both microvascular and macrovascular complications (45). Having a clear comprehension of how the disease develops will give researchers a clear path to the development of drugs and proper interventions that can help the people suffering from this condition (28).

Diabetes and Pre-diabetes

The hallmark of Type 2 Diabetes is abnormally high levels of blood glucose or hyperglycemia. However before the onset of Diabetes the body goes through a period of elevated blood glucose termed "Pre-diabetes". Pre-diabetes is a condition defined by "impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)" (29,11). Impaired glucose tolerance is defined as two-hour glucose levels of 140 to 199 mg per dL (7.8 to 11.0 mmol) using the 75-g oral glucose tolerance test, and impaired fasting glucose is defined as glucose levels of 100 to 125 mg per dL (5.6 to 6.9 mmol per L) after an 8 hour fast (11,35,39). To be successful in combating the current surge of diabetes, it is imperative that we understand the etiology of pre-diabetes to diabetes (33). Perreault and colleagues reason that we should explore all avenues that may enable us to know the blood glucose levels at which to start lifestyle intervention (33, 37, 38). Our ability to identify and treat people who are developing these early signs of diabetes could be a good starting point in our quest to reverse the current trend. The prevalence and the constant rise of the type 2 diabetes, calls for creative and innovative ways to treat, and deal with this disease. One way would be to find people who do not yet have diabetes but are in a state of insulin resistance. The Impaired Glucose Tolerance Test (IGTT) could be an appropriate tool if it is used, and is deemed successful, in identifying people who are at a greater risk of developing diabetes (39). The use of "IFG alone or in combination with IGT" has given us the ability to identify and classify patients who have pre-diabetes (13). Schwartz reported in 2007 that "impaired fasting glucose predicts the development of IGT and diabetes (37). This could be very useful for scientists and other health professionals to help reverse the upward trend and prevalence of diabetes. They would be able to identify those people who are at risk of developing diabetes; and provide education and interventions to stop fast growing diabetes prevalence. One of the problems that most people will encounter will be trying to determine when to get tested and what risk factors they should look out for. One of the problems with this is that IGT does not show any symptoms and scientists have not yet associated it with any known disabilities or disorders (39). Perhaps the best case would be to have people be tested and know their glucose level, using IGTT as it is less expensive and is a good clinical test.

Etiology of Type 2 Diabetes

Insulin Resistance

Insulin and glucagon are homones produced by pancreatic cells. Insulin helps to usher glucose into the cells when glucose is present in the blood and to the liver and muscles for use and storage. While glucagon stimulates glycogen catabolism from the muscles and the liver when the blood glucose levels are low, and will signal the pancreas to stop insulin production when blood glucose levels increase. This negative feedback loop will continue, and will maintain blood glucose homeostasis.

When the body is functioning normally, insulin is released from the pancreatic β cells into the blood in response to the increased levels of blood glucose. This generally happens after consuming some food. Insulin will be increased in the blood and will help lower the blood glucose levels by facilitating the uptake of glucose into the cells.

The body may fail to use insulin properly either due to insulin deficiency, or the body's inability to use the available insulin. If hyperglycemia is the result of the body's inability to use insulin, and the β-cells are functioning, then the β-cells may become exhausted due to increased insulin demand. The blood glucose level then will rise to abnormal levels. Pancreatic β-cells may also be exhausted due to increased insulin demand and the body's natural ability to maintain glucose homeostasis becomes overwhelmed. This leads to insulin resistance. After a long period of having insulin resistance, the body will eventually progress to pre-diabetes and eventually diabetes (43)

Type 2 diabetes does not develop overnight. After years of elevated levels of glucose in the blood and the inability of the body to clear glucose fast enough from the blood, the body develops insulin resistance. Insulin resistance may develop simultaneously with elevated blood glucose levels or one may precede the other. This occurs when insulin binds to the insulin receptors on the cell membrane, insulin resistance will result when the numbers of receptors are reduced or their function is diminished. Insulin resistance can be defined as a condition in which the body fails to respond to insulin properly. Rhee and colleagues defined insulin resistance as a resistance to the metabolic effects of endogenous insulin secretion (36). This resistance occurs when glucose concentration increases while glucose appearance exceeds glucose disappearance in the blood. If the increase continues until these two rates are once again equal then the body will remain in a normal state of glucose concentration (13). This happens because when the cells 'resist' insulin, the pancreas will continue to produce more insulin because of high blood glucose levels. During the onset of T2D diabetes, insulin resistance and insulin secretion may both increase at the same time resulting in patients showing normal blood glucose (13, 36). This is because in most cases, in presence of insulin resistance some insulin receptors still function and some amount of glucose is metabolized. Also, according to Rhee when endogenous insulin production falls because of β-cells exhaustion, and the pancreas is not able to produce adequate insulin to compensate for the increasing insulin resistance (36). However, later when the body has developed diabetes insulin levels may become normal again. With this conundrum the body will have to act vigorously to transport the rising glucose into the cells; however, with the onset of insulin resistance this will be a task too difficult for the body. The negative feedback loop will not help as insulin receptors are decreased or defective. Glucagon production may be inhibited by the high levels of insulin in the blood. Blood glucose increases and may be at much higher levels. Over a period of time this will eventually lead to sustained elevated serum glucose levels and a diagnosis of diabetes.

Factors that Contribute to the development of Type 2 Diabetes

Adult and Adolescent Obesity

There is an increase in the prevalence of diabetes and pre-diabetes in the adult population, and that of obesity among the adolescent populations (16). T2D was previously thought to be "adult onset" diabetes, it is now diagnosed in 40% and, as high as 50% of all adolescent diabetes cases in certain parts of the US according to the ADA (62, 63). This is of enough concern to call for a major policy change to avoid a serious public health catastrophe (16, 18). The diagnosis of diabetes usually follows the diagnoses of obesity or overweight (14). In children from the ages of 2-19 BMI is mostly measured using the growth chart. In the growth chart children who were at the 95 percentile range were said to be "overweight" as recommended by expert committees (53, 54). Ogden reported that lately adolescents who fall in the 95 percentile in the growth chart have been termed "obese" (53, 55). As a result 18.1% of the adolescent children were obese as reported in the latest National Health and Nutrition Examination Survey (NHANES) data. The same survey also estimated the adult obesity rates at 33.8% (56). Overweight and obese children are likely to grow up and become overweight and obese adults.

It has been reported that about 90% of the people who have type 2 diabetes are overweight or obese (14, 22, 56, 60, 61). And a number of studies have shown that increased subcutaneous abdominal fat, or increased visceral fat; and particularly if the two conditions are coexisting may underlie central adiposity (1, 14, 22). However, when using a CT scan, Bray and colleagues found that subcutaneous fat measured by CT scan did not predict diabetes in their study. They also reported that waist circumference was a much better predictor of diabetes (14).

In an earlier study of participants who were in a fat and weight reduction targeted exercise regiment, Carr and colleagues found that people who decreased their weight and body fat had a better insulin sensitivity. They also found that the decrease in "weight and intra-abdominal fat, but not percent body fat or abdominal subcutaneous fat, were associated with a 24-month positive improvement in β-cell function" (1). This information should be borne in mind for understanding the complexities of the disease and when designing interventions that could save and restore the quality of life for many people who may be affected with type 2 diabetes.

Obesity will likely result in insulin resistance. However people who have strong and properly functioning β-cells will be able to remain in the state of insulin resistance with less chances of developing diabetes with visceral adiposity increasing the chances of developing diabetes.

Fat distribution, visceral or peripheral

Peripheral subcutaneous fat is the fat that is deposited under the skin and is mostly well distributed over the body mostly in the hips, upper arms and thighs. While visceral fat is stored in the abdomen and it thought to have a high metabolic activity level.

When fat is accumulated in organs such as the liver and muscle, it is likely to impare the function of organs and this may contribute to insulin resistance (48, 49). This may also be caused by increased lipolysis, along with impaired glucose uptake which will lead to elevated free fatty acids. This will eventually lead to insulin resistance. Fatty acids will bind to the cell membranes of non adipose cells and this will result in the impaired function of the tissue. An example of this would be skeletal muscle cells which will be less efficient if the free fatty acids bind to their membrane for glucose uptake (58, 59). The American Association for the Study of Liver Diseases reported that High levels of fat and fatty acids can lead activate some serine kinases in insulin sensitive cells (58). This could happen in the adiposities, liver and skeletal muscle cells. Once activated, the kinases will lead to "inflammation and cell adhesion" (57, 58, 59). Individuals whose fat mass is mostly distributed as peripheral subcutaneous fat may result in less risk for development of diabetes; while fat that is mostly distributed in the abdomen will results in an increased risk for diabetes. This is because abdominal fat contribute to the development of insulin resistance by releasing free fatty acids into the blood. About 90-95% of all people with diabetes have type 2 diabetes and about 90 % of those who have type 2 diabetes are either overweight or obese (60, 61).

Environmental Factors


If a diet consumed is high in calories and saturated fat, then this will likely result in the development of obesity.. A balanced diet is one of the most effective ways in diabetes prevention and treatment. The 2005 Dietary Guidelines for Americans recommends that a person on a 2000 kcal diet plan should consume a diet composed of 45-65% kcal from carbohydrates, 20-35% from fat(less than 10% of this from saturated fat), and 10-35% of protein (68). And the USDA My Pyramid recommends that such a person should consume at least 2 cups of fruits, 2.5 cups of vegetables, 6 oz of grains, 5.5 oz of meats and legumes, 3 cups of milk, and 6 teaspoons of oils each day (69). However when people are given a choice they seem to select foods which are high in saturated fat and low in vegetables and fruits and whole grain (64, 66, 67). It is possible to consume only foods that are considered to be healthy, and still become overweight or obese or even develop diabetes. As a result, while it is important to consume foods that are high in fiber and whole grain, the total amount of calories consumed should be considered (67). For people living with diabetes, keeping the blood glucose levels as close to normal as possible is the major goal. But this could be hard to achieve for most patients and since diabetes could be caused by different factors in different people, one approach may not achieve desired results for all diabetes patients (64). An individualized approach is therefore vital for a successful diabetes treatment. However, treating diabetes with diet has to be a challenging task because changing what people are accustomed to eating or changing the foods that define their culture is daunting tasks (65, 66). A weight loss diet is also recommended and through lifestyle changes including caloric restriction and physical activity people may be able to reduce their weight. However it has been reported that most people who lose their weight regain one year later (67). This may also explain the ever increasing obesity and overweight rates which has a negative impact on the diabetes rates.

Physical Activity

Along nutrition, Physical activity is a major component of major component of maintaining a healthy lifestyle. The CDC defines physical activity as "Any bodily movement produced by the contraction of skeletal muscle that increases energy expenditure above a basal level" (71). Drawing from this definition it would be wise to state the difference between physical activity and exercise because the two terms are sometimes used interchangeably. Exercise is a kind of physical activity which is usually designed and structured to increase physical fitness (71, 73). There are three components that can be used to assess the level of physical activity and these are frequency, intensity and duration.

The frequency of the exercise or physical activity is an important aspect of the exercise program. The CDC and the American College of Sports Medicine (ACSM) recommend that people should maintain 30 min of moderate physical activity for 3 to 5 session times a week (71, 73). The intensity of an exercise program can be measured using the metabolic equivalent (MET), where 1 MET is the rate of energy expenditure while sitting at rest (72). With this in mind the intensity of an exercise program can be defined as being of a light, moderate of vigorous activity. On a scale of 0-10 low intensity would require the energy expenditure of less than 3 MET, while 3 to 5.9 would be moderate intensity and 6 to 8 will be classified as intense (71).

It is important that an exercise should reach the objective for which it was initially intended. An exercise program should be performed for the duration prescribed. A number of studies have shown that physical activity along with diet can prevent, delay and reduce the risk of developing diabetes (11, 19, 20, 26, 31, 40, 41, 46, 47). For diabetes management and risk reduction, blood glucose metabolism should be borne in mind in order to achieve the desired results. When performed at the above mentioned recommended levels physical activity may produce many benefits including improvement of carbohydrate metabolism, insulin sensitivity, reducing cardiovascular risk, weight loss and weight maintenance among others (71).

Genetic Factors

There is some evidence that fasting plasma glucose is increased when the β-cell function is decreased and that this may explain the subsequent increase in IFG for Type 2 diabetes (8). Type 2 Diabetes can be characterized by the high blood glucose levels that continue to increase, this leads to hyperglycemia (47). Obesity is a major risk factor for diabetes but if β-cell dysfunction is in conjunction with insulin resistance, this will lead to an early onset of diabetes (18). If the body reaches a definite β-cell function decline caused by genetic disposition or other factors that lead to low insulin levels (36). This will lead to a cascade of events which will lead to the development of Type 2 diabetes (18, 36). This could be due to the fact that β-cell capacity has been reduced to such low levels that it is not enough to compensate for the insulin resistance. Hyperglycaemia, will then get worse and diabetes will eventually develop (46). However, on the other hand the decline in β-cell function could be caused by insulin resistance. This happens when the body is unable to use the available insulin (8). It has been reported that even after weight loss maintenance, people who are at a high risk of developing diabetes are still likely to experience continued declining β-cell function (1). This could be explained by an understanding that a reduction in β-cell function may improve the fasting plasma glucose which could have adverse effect on β-cell function (8). Mayer et. al. found that β -cell function was impaired in individuals who had impaired fasting glucose, but not impaired glucose tolerance individual by measuring basal insulin release (29).

Glucocorticoids will be increased due to stress either physiological or psychological but the elevated and chronic levels of glucocorticoids will lead the body into insulin resistance by leading the body to obesity, particularly visceral obesity. Glucocorticoids leads the body to insulin resistance by reducing glucose production and also reducing glucose uptake. The enzyme 11β hydroxysteroid dehydrogenase type 1 (11β HSD-1) will result in the regeneration of glucocorticoids and will contribute to the chronic elevation of glucocorticoids.

Genetic predisposition to proper function or impaired function

When insulin secretion is down in the pancreas due to impaired β-cell, the following could happen:

-The brain will receive low amounts of insulin and this will result in more food intake and will eventually lead to obesity and insulin resistance.

-In the liver low insulin will mean that there needs to be an increase in glucose production, this will lead to an increase in plasma glucose.

-In the muscle glucose uptake efficiency will be reduced meaning that glucose will remain in the plasma.

- In the adipocytes lipolysis will increase resulting in more production of the NEFAs this will feather increase insulin resistance and degrade the β-cell function.

The Following diagram represents different factors that may contribute to the development of type 2 diabetes. Each factor on the central circle is explained in the outer boxes, with both negative and positive signs indicating the influence of each action given on a person chance of diabetes health.

Insulin Resistance

-High levels of triglycerides in the blood, obesity, high levels of glucocorticoids.

+ Healthy diet and physical activity will reduce the high levels of triglycerides acids and a if the stress induced glucocorticoids may be reduced.


- Once a person is obese they may have a larger number of adipose cells and it may be much harder to lose weight or to lower the number of calories they consume

+ Physical activity and restricting high calories foods and reducing the number of calories consumed will help reduce the body fat

Genetic factors

Genes may be responsible for the development of diabetes for a person who develops diabetes, while others who are obese and insulin resistant do not develop diabetes. The answer may be the health and resilience of the β-cells

Environmental Factors

- Environmental factors such as lack of physical activity and consumption of food that is dense in fat and calories may result in obesity

+ Consuming a healthy diet and exercising regularly would be a good way to reduce the chances becoming obese

Increasing Rates of Diabetes

Banjamin et. al reported that about 25% of the overweight adults who are between the ages of 44 and 75 have pre-diabetes, a translation of about 12 million adult Americans in the year 2000 (12) and the CDC reported the number to be 24 million by the year 2008. By 2006, another report indicated that an estimated 35.3% of the adults in the US had diabetes or pre-diabetes, this percentage translated to about 73.3 million Americans. The CDC National Diabetes Fact Sheet report of 2007 stated that about 23 percent of the adult population over the age of 60 in the U.S. had diabetes (CDC, 2007). In 2008 the CDC reported that Type 2 Diabetes has increased by up to 90% from the 1997 data, to arrive at this conclusion, the CDC averaged the study data over two-year periods. The latest data, from 2005-2007, was compared to data from 1995-1997. The complete data are for 33 states. Here's the CDC's list of states, in order of annual, age-adjusted diabetes rate per thousand residents. Increases compare rates from 2005-2007 to rates from 1995-1997. What was also disturbing about the report was that more than 60% of those who had the disease did not even know about it (CDC, 2008).

The Southern States

While the diabetes rates have increased throughout the U.S., the rate of increase was much higher in the Southern states. In South Carolina the rate of increase was 113%, the percentage was obtained by comparing the diabetes rates from 2005-2007, with those from 1995-1997 as reported by the CDC. The CDC report showed that of all the states surveyed, South Carolina had the second highest increase in the prevalence of diabetes. And of the 33 states surveyed, this was second only to West Virginia which had an increase of up to 119 % (CDC, 2008). Type 2 diabetes is growing at a very fast rate in American and it continues to have a negative impact in the society (45). The current prevalence rate and the continuing upward trend of the disease will continue to be a major problem in the American adult society. The disease has been shown to be an emerging condition of major concern for American children also. The current increasing rate for adults and adolescence, both indicate that diabetes will continue to be a major cause of concern for the American public even in the future (18). Lyssenko and collogues reported that a family history of type 2 diabetes was a major risk factor for the development of diabetes. They also indicated that the risk of diabetes was not reduced for the second relative of the diabetes patient (2). This is particularly disturbing given the report by Cowie and colleagues indicating that about 35.3% of the adults in the US had diabetes or pre-diabetes (16)

Worldwide Prevalence

The increasing diabetes prevalence is not isolated to the United States. Incidents of diabetes continue to increase in the US and around the world. Many countries around the world are facing a similar problem. The diabetes prevalence is increasing in all populations around the world (46). Scientists have warned us about the problem of diabetes and its consequences around the world for many years now. However, not enough has been done to avert the continuing trend. In 1997, Pan and colleagues warned about the risk of diabetes and its consequences for the world community. In their paper, they warned that diabetes would lead to "vascular complications that give rise to considerable morbidity and premature mortality" (32). The worldwide rise in diabetes rates could be blamed on many factors. But some scientists have indicated that "population growth, aging, urbanization, and increasing prevalence of obesity and physical inactivity" are the main contributing factors (44).

Diabetes and insulin resistance are conditions affecting the developed nations as well as developing nations. This indicates that diabetes is quickly becoming a worldwide problem. An interesting observation is the older peak age for diabetes prevalence as observed by Motala and colleagues in South Africa (30). This is also the case in China where the prevalence of diabetes increases with age and personal annual income and is about three times higher than 10 years ago (32).

Diabetes Complications

Many studies have documented a strong correlation between diabetes, pre-diabetes and heart disease, and low life expectancy (3, 12, 21, 25) and that intervention could help improve them all together. (46). In their study, Benjamin and colleagues found that among "adults with pre-diabetes, the prevalence of CVD risk factors was high: 94.9% had dyslipidemia, 56.5% had hypertension, 13.9% had microalbuminuria, and 16.6% were current smokers" (12). Diabetes takes a toll on the body because it usually occurs with "a clustering of established risk factors such as hypertension, hypertriglyceridaemia, low HDL-cholesterol, high concentration of small dense LDL" sometimes classified as metabolic syndrome (25).

Diabetes and Pre-diabetes Intervention and Prevention

With such an overwhelming evidence and information indicating the detrimental effects of diabetes, we need to find a meaningful way to delay or prevent diabetes. It is important that we use preventative measures such as physical activity and healthy eating habits to delay or prevent the onset of diabetes. We also need to define the early processes that take place before the onset of diabetes. We should also find ways to recognize and treat insulin resistance, in the meantime; however, we can diagnose pre-diabetes.

The American Diabetes Association (ADA), classifies a person who has fasting plasma glucose of at least 100 mg/dl (5.6 mmol/liter) but less than 126 mg/dl (7.0 mmol/liter), as being pre-diabetic (ADA). There is a great interest in the medical community to detect diabetes and pre-diabetes in the early stages or even before they become serious conditions (17), and since the development and progression of pre-diabetes to diabetes occurs over many years it is desirable to detect diabetes before "the overt hyperglycemia seen in diabetes"(43). Because pre-diabetes is asymptomatic patients usually don't know what to look for and as a result, pre-diabetes may go undetected until someone has diabetes (39, 46). Another problem is that those limited available methods of treatment such as drug treatment remain inadequate and do not provide a cure, as a result prevention is desirable (26). Preventative intervention seems to be the only viable and reasonable option, and with more than 73.3 million Americans who have diabetes or pre-diabetes, an intervention may be the best option (12, 16). A successful intensive intervention for both diabetes and pre-diabetes will be challenging and it will not produce the desired results overnight, because obesity (as one of the main contributing factors) and diabetes develop over many years (43). It is likely that interventions will have to be both a lifetime change with "community and organizational support providing expertise and resources" (11). It is inevitable that the cost of this kind of intervention will be large and it would be wise to have reliable risk and cost assessments prior to embarking on such a large endeavor (32). The cost of large intervention studies may be substantially high in monetary and emotional terms; however, the "projected morbidity and mortality that will be conferred by the occurrence of T2D in most Americans, including those of a young age," calls for this kind of investment (18). Investing in the community's health will be helpful and rewarding for the public and will reduce the public health burden of diabetes (26).

Many studies have shown that diabetes can be prevented or delayed by lifestyle intervention in people who are in a pre-diabetic state, and that reduction in weight and an increase in physical activity can decrease the risk of developing diabetes for people who have pre-diabetes (15, 26, 31, 41). Some of the most famous diabetes intervention studies are the Chinese Da Qing IGT and Diabetes Study, Diabetes Prevention Program, as well as the Finnish Diabetes Prevention Study, and in both studies, researchers found that over a period of 3 years and more there was a reduction in the development of diabetes by 42-58% in their lifestyle intervention programs (1, 19, 32, 40). In the Finnish study researchers found that "weight reduction and improved fitness were equally correlated to improved glucose tolerance, whereas subjects who both reduced weight and increased oxygen uptake improved most" (19). This indicated that weight reduction along with physical activity were the best intervention when applied together than when each was applied individually. Also in a follow up study Eriksson and collogues reported that there was "great improvement in the metabolic changes in an intervention supports a successful continuation of a study, if lifestyle changes remain permanent, and the onset of Type 2 diabetes could be postponed by several years" (19). In 2005, Carr and collogues reported that Lifestyle modifications consisting of the American Heart Association (AHA) Step 2 diet and endurance exercise for 24 months in Japanese Americans with IGT resulted in significant weight loss, reduced percent body fat, decreased visceral and subcutaneous abdominal fat, and increased insulin sensitivity (1). Interventions may need to be designed differently for each community taking into consideration the cultural and social aspects of the given community (26).When designing an intervention it would be wise to focus more on the communities that are severely affected by obesity and diabetes, this may help reduce the prevalence of diabetes in the future (44). It should also be noted that it may be better to introduce lifestyle interventions to people who are at a higher risk of developing diabetes even before they have pre-diabetes, especially those who are obese because "the propensity of individuals to gain weight over time and the ongoing loss of β-cell function may well limit the ability of lifestyle interventions to prevent type 2 diabetes over the long term." (1). It would also be challenging for public health professionals to single out obese people to participate in interventions because not all obese people develop diabetes.

Those who have pre-diabetes should be given a priority as they are at a much higher risk of developing diabetes (46). "The reduction in the risk of developing type 2 diabetes with lifestyle modifications in individuals with IGT may occur due to improvements in insulin sensitivity, β-cell function, or both" (1). It has been reported that "increasing regular physical activity and preventing weight gain could be essential order to slow down transition toward the high visceral adipose tissue and high insulin resistance state shown to display the highest metabolic risk" (34). It is well established that the Western lifestyle which encourages sedentary behavior is one of the main causes of obesity and diabetes, and countries attaining this lifestyle see an increase in their obesity and diabetes incident (46). As a result lifestyle interventions may be the best way to reverse this trend.


While most studies including the The Da Qing IGT and Diabetes Study, Diabetes Prevention Program, and Finnish Diabetes Prevention and " Carr et.al showed insulin sensitivity improved with diet and exercise, there have been some "setbacks" (not sure this is the word that you want to use here) with some studies lack of improvement in β-cell function or glucose tolerance (1, 34, 46). With this overwhelming evidence it is fair to conclude that since the current drugs and medications have shown little or no success to combating the onset and prevalence of diabetes, it would be better to use preventative measures. Diabetes interventions have been shown to be an effective way of treating and delaying diabetes, it is clear that diabetes intervention with exercise and diet is the best approach to treating and preventing diabetes.