The Diabetes Risk Assessment for the 92% of Us Who are Insulin ResistantJune 05, 2022
The Diabetes Risk Index: A New Predictor of Future Diabetes Risk
Diabetes is the human Achille's Heel. Getting it is bad. Being overweight correlates highly with being diabetic. The problem is that nature wants you to be fat. We evolved in ecosystems where food was not plentiful year-round, and prolonged periods of calorie deficiency (winter in Asia and Europe, dry season in Africa) were the norm. Putting on weight needed to happen when easy calories were abundant. At the end of the growing season, many plants have fruiting bodies like seeds, nuts or fruits that were seasonally available, so we ate them as fast as we could, and gained a little weight. Today we have those delicious foods available for us year-round. The tightrope of calorie control is too hard for most of us to navigate. Our calories are too easy. We get fat and diabetic.
The definition of diabetes started out in Hippocrates' time as "sweet urine" that ants would migrate to. We know we spill glucose into our urine when we exceed a blood glucose of 180. Ok. With the advent of lab medicine, we refined our definition of diabetes to being two measurements of fasting blood glucose of 126. We learned that absolute deficiency of insulin was one type of diabetes, but insulin resistance was the far more common and insidious form. Type II. Lots of insulin around, just not working well. And that also turns out to be a continuum of risk. The first crack in the wall came with the Whitehall Study out of England showing that a glucose of insulin 86 was the threshold for finally being rid of diabetes risk.
The definition of Type II diabetes has also been evolving. We switched from the definition of Type II being a high blood glucose to the Hemoglobin A1c. A1c stands for the percent of hemoglobin molecules in a red cell with a glucose attached. Red cells live 100 days or so, so the A1c reflects the average glucose over the last 100 days. That's much more stable than the wildly swinging blood glucose. Even the A1c reflects a continuum and has been refined. The Institute of Medicine, our nation's arbiter of guidelines, used to define the target for optimal health of A1c as 6.0 and type II diabetes as an A1c of 6.4. Those goal posts were changed to an optimal A1cof <5.7 about three years ago. Medicare pays extra to health systems to get their patients' A1c below 7. Out of control folks will be 8, 9, or worse. Getting to 12 and 13 is lethal.
The final step of discovery was recognizing that insulin is actually the key. If we can make enough insulin, we can control our blood sugar. But we can't. We only have the capacity to make some pre-determined quantity of insulin, and then our pancreases poop out. That means there are two variables, glucose and insulin, and insulin eventually runs out of steam. Then, we become "diabetic".
Ok, we have the definition of Type II diabetes down pat. But we recognize that it is a continuum which generally gets worse as we put on more weight and become insulin resistant. Can we look into the future and predict who is going to get worse? That's the key.
So, now we have developed two tools to do just that. The HOMA-IR(Homeostasis Model Assessment of Insulin Resistance) has been around since the 80s but not widely used. Do you know your HOMA-ir score? You should. It's easy to calculate. The formula is = fasting insulin (microU/L) x fasting glucose (nmol/L)/22.5. A score of 1 is great. Anything above 2 is suspect for early insulin resistance. There are lots of websites that will calculate it for you. You just need an insulin level.
But the evolution of diabetes risk continues. It's not just the glucose level that is going astray. Curiously, the branched-chain amino acid levels in your blood are strongly predictive of the development of Type II diabetes. Finally, the advent of laser measurement of lipid subfraction particle sizes allowed precise size measurement of lipid particles in the blood. And they predict future diabetes even better!
Can we combine the two? Aha, Labcorp has done just that. The DRI, Diabetes Risk Assessment combines the lines of evidence: the LP-IR score, a measure of insulin resistance based on the Women's Health Study and Branched Chain Amino Acid levels. It measured the size of HDLs, VLDLs, and LDL particles which correlate strongly with insulin resistance.
The PREVEND study was published in August of 2020. It followed 6134 subjects for over 8 years and measured these variables to develop the new index, the Diabetes Risk Assessment. They found a 12-fold predictive variability from the top to bottom 20%. The DRI is more predictive of future diabetes risk than any prior measurement, including the HOMO-IR, the BMI, or individual scores.
This is a huge advance. We can now look prospectively into the future. With data, we can catch and measure and find trouble early. The vast majority of folks don't know any of this data. And the majority of folks I've measured it in didn't have a clue they were in trouble.
www.What will Work for me. Well, I measured my HOMO-IR and DRI with Labcorp. My Homo-IR used to be above 3. I'm now down to 1.9. What a relief. That took me a couple of years to get there but I keep chipping away. My DRI came in at 33, but that was after I spent four months wearing an insulin monitor and changing my eating habits quite dramatically. The goal is to be below a score of 50 for men, 40 for women. Higher than 65 is serious trouble. So, I've taken my risky genetic profile and been able to nudge it down into the safety zone. You may want to consider doing the same. Ask for the Diabetes Risk Index test from Labcorp. I'll order it for you if your own doctor won't.
References:J Clin Medicine, News Medical Life Science, Diabetes Care, CDC, Diabetologia, MDCalc, Nature, J Clin Lipidology, J Clin Med,
1. What is the definition of diabetes? Answer: It has been a moving target but we now call it a Hemoglobin A1c of 6.4%.
2. What is the optimal level of A1c for longer life? Answer: Less than 5.7%
3. What happens to my lipids with insulin resistance? Answer: the size of various subfractions changes dramatically. Generally, bigger is better. Fewer is better.
4. What are branched-chain amino acids? Answer: the ones we measure are called leucine and valine. They are literally branched in shape. They are more common in animal proteins and legumes and are critical to building and maintaining muscle mass. But too many, not so good.
5. And what do I want my DRI to be? Answer: Less than 50 as a man, 40 for a woman.