SKYAID
New 
Mission
Overview   
Details    
Medical   
Watch   
Heart attack  
Stroke    
World health  
Emergency
Cost effective
Media 
- Site Map 

SKYCAR   
Details   
Overview  
VTOL   
Airline   
Military   
Transportation
Images 
- Site Map

Search

Translate 
  8 languages
 

Facing down a killer disease
Diabetes is striking millions, from teens to boomers. But there are ways to beat it

By Josh Fischman  U. S. News June 25, 2001 http://www.usnews.com/usnews/issue/010625/health/diabetes.htm

   Jump to sections:   Heart Disease,  Lack of information - from doctors

Frank Papsadore has stopped running. The 42-year-old advertising executive stopped running his high-powered Boston agency. He stopped running his coworkers into the ground with his lousy temper. He stopped running for slices of pizza between endless rounds of meetings. "I'd always been an athlete. But I was getting fatigued, almost passing out in meetings," he says. "And when I wasn't doing that I was angry, yelling at people. Plus, I was running to the bathroom about 20 times a day. I knew something was up–that I had to see a doctor."

The doc told Papsadore his weight was killing him. "During my 30s, I gained about 125 pounds," he says. "I got up to about 350, on a 6-foot frame." Papsadore's fat was the kind that steals your eyesight, rots your limbs, and shreds your nerves. It rips at your heart, and can rob five to 10 years from your life. It was diabetes fat.

Now Papsadore walks. Every morning, he covers at least 3 miles near his house on Cape Cod. He's also on his feet as Sandwich High School's volunteer football coach, and every evening he walks into a kitchen filled with food like grilled tuna–in controlled portions, of course. After the shock of being diagnosed with one of the country's fastest-growing and most dangerous diseases, Papsadore decided to control it, with changes in his diet and lifestyle. So far, he's one of the lucky ones.

About 16 million people in this country suffer from diabetes. That's up nearly 40 percent in the past decade–and almost all have a form of the disease called Type 2 that's usually tied to obesity. But this is no ordinary disease. It's an epidemic that breeds others. Blood sugar run rampant–the hallmark of diabetes–poisons vital organs. Among U.S. adults, diabetes is the leading cause of blindness and kidney failure. It can quadruple the risk of heart disease and stroke and lies behind 90,000 amputations a year. Overall, it's the seventh-leading cause of death in the nation. And it's getting worse: The American Diabetes Association predicts that a million more sufferers will be diagnosed every year.

The ailment is also affecting younger people than ever. In the past decade, the incidence among people in their 30s has jumped by 70 percent. It's up by nearly 10 percent among the under-30 crowd. "It was a shock, I tell you," says Moira Dresser, 29, of Bellingham, Mass., who was diagnosed a year ago. "You don't think about getting it in the prime of your life."

The epidemic is even hitting teenagers and grade schoolers (see related story). "This whole thing gets pretty scary," says Cameron Akbari, a vascular surgeon at Beth Israel Deaconess Medical Center in Boston who has to remove diabetics' gangrenous toes. "With people getting it at younger ages, they'll be struggling with amputations and blindness and heart disease for longer than ever before."

Diabetes cases have exploded for one key reason: the 60 percent increase in obesity over the past decade. "Sure there's a genetic predisposition to diabetes, but the incidence has gone up way too fast in 10 years, and genes don't change that fast," says Allen Spiegel, director of the National Institute of Diabetes and Digestive and Kidney Diseases in Bethesda, Md. "So it's got to be the environment. And our environment is filled with fatty foods and very little exercise."

But look deeper, and there are signs of hope in this grim picture. A recent study shows that moderate weight loss and an exercise program can cut the risk of developing diabetes by more than half in people at risk. Even those with the disease can reduce symptoms by losing weight. A new class of drugs, called TZDs, offers fresh hope for controlling blood sugar, or glucose. A simple test four times a year offers diabetics a score card showing how well they're managing their disease. And a new long-acting insulin–the hormone that normally controls glucose–has just come on the market, offering still more promise.

Sadly, however, some aspects of the disease are proving stubbornly resistant to change. Medicine hasn't been able to make much headway against diabetic heart trouble, which will be a central topic this week at the diabetes association's meeting in Philadelphia. Another trouble spot is doctors. A recent survey found most of them don't give their patients regular tests that can show if they're managing well or headed for diabetic disaster. "That's just a tragedy, because it means patients are out there on their own, trying to master some difficult medical problems," says Richard Jackson, a physician at the Joslin Diabetes Center, affiliated with Harvard Medical School.

Sugar and fat. For an illness with so many complications, the definition of diabetes is startlingly simple: You have it if your blood sugar level is more than 126 milligrams per deciliter after an overnight fast. (Normal blood sugar levels are between 70 and 110 mg/dL.)

The reason for the elevated blood sugar is a defect in insulin, which is made in the pancreas and normally helps glucose enter the body's cells to be used as energy. In Type 2 diabetes, either the body doesn't make enough insulin or cells begin to resist it. (In Type 1 diabetes, which affects about 5 percent of people with the disease, the body simply does not make insulin.)

A family legacy of diabetes can be enough to put some people at high risk. But for most Type 2 diabetics, excess body fat is at the root of the insulin problems. Fat doesn't just sit there. Among other substances, fat produces a hormone called resistin, which makes it harder for insulin to escort sugar into cells–it's an energy conservation measure. Too much fat means more resistin and less glucose in cells. The pancreas at first reacts by making extra insulin, but over months and years it exhausts itself. As the body tries to compensate hour by hour for these defects, glucose and insulin levels swing from high to low and back again. High levels damage blood-vessel walls, ruining circulation. Over time, this harms the heart, nerves, kidneys, and eyes–all of which need oxygen carried by blood to survive. Low glucose levels cause exhaustion, as cells have no energy to burn, and can lead to a diabetic coma.

Getting tested for an inability to handle glucose is straightforward. Yet it's a step too few take. An estimated one third of the 16 million diabetics don't realize they have the disease. "Anyone with a family history, with high blood pressure, who is overweight, should get tested every year," particularly if there are other warning signs like thirst and frequent bathroom runs, says Francine Kaufman, a pediatric endocrinologist at Childrens Hospital Los Angeles. After you fast overnight, your doctor draws some blood to test the glucose level. Under 110 is normal. Between 110 and 126 shows impaired glucose tolerance, a prediabetic state; diabetes strikes at 126.

What if you hit that number? "I froze up. It was like hearing I had cancer," says Keisha Roberson, 30, an administrative assistant at the University of Massachusetts in Boston. Roberson had relatives with the disease–and memories of them injecting insulin, going blind, losing toes. Roberson, as an African-American, was already at higher risk for the disease, which is more common among many minority groups (see related story). "Diabetes seemed really hard core."

It is. Yet hard-core complications often can be avoided by controlling the sugar swings. Two large studies that used insulin injections or diets to keep blood sugar in the normal range showed this could reduce many complications by a quarter or even half. So getting sugar under control has become the touchstone of treatment. Diabetics check their sug-ar several times a day by pricking their fingers to draw a drop of blood and measuring the glucose level with a small meter. There are three main tools for controlling that level, says Emmy Suhl, a diabetes educator and dietician at Joslin: "The first is exercise, and then there's diet, and finally there's medication."

The reason exercise comes first is that it's positive, says Joslin's Jackson. "Diet, in contrast, seems like a deprivation. There's no good weight-loss program without exercise." Exercise also moves more glucose out of the blood and into muscle cells, which need fuel when they're working harder.

You don't need to do a lot, Jackson adds. You just need to do it regularly, and it can have a major effect. Roberson, who is overweight, has just started walking, lost 6 pounds, and has been able to stay off medication. Andrea Levine, a cheery-sounding 14-year old from Hampton, N.H., who is 270 pounds, started doing Tae Bo–but not regularly, she admits–"and I do walking around my neighborhood. What I really like now is that it's summer and I love to swim."

Learning to count. But exercise without dieting is rarely enough. "Ah, food, the dreaded subject," Levine says. "I try, but I come from this family background where food is comfort." Even so, she has been working on portion sizes and carbohydrate counting. It's not just sweets. Diabetics need to realize that candy and pasta and potatoes are all carbohydrates and ultimately get treated the same way by the body: as glucose. Fats also need to be minimized. You have to watch how much of any food you eat, but even as a diabetic you can eat small portions of almost anything.

Frank Papsadore decided to tackle the portion problem by hiring a professional chef. "It's not as expensive as it sounds," he says, figuring that for $240, including food, he and his wife get two weeks' worth of dinner–flounder, chicken piccata–at set portions. "We were spending $200 every two weeks cooking for ourselves, so this really isn't much more." He's down 30 pounds to 320 and has been able to stop taking medication while keeping his blood sugar near normal.

The potency of a diet-and-exercise combination was brought home last month by the Finnish Diabetes Prevention Study, which looked at a few hundred men and women with impaired glucose tolerance–the warning sign of heightened diabetes risk. They were given modest weight loss and exercise targets–losing 5 percent of body weight, for instance–and compared with a similar group without those targets. After three years, the dieters had less than half the rate of diabetes of the other group. "They weren't trying to be Britney Spears or Charles Atlas at the beach," says Edwin Fisher, associate director of diabetes research and training at Washington University in St. Louis. "The objective was small. But it made a huge difference."

In full-blown diabetes, however, lifestyle changes often aren't enough. Medications like Glucophage help by keeping the liver from releasing extra glucose between meals. The newer TZDs, which include Actos and Avandia, do that plus make cells more sensitive to insulin.

About 40 percent of Type 2 diabetics, mainly those whose pancreas doesn't make enough insulin, also need insulin injections. A new type of insulin, just introduced in May, may reduce the number of shots from two or three a day to one. Called Lantus, it lasts for nearly 24 hours at a constant activity level. "It makes things much smoother," says Doug Granados, 54, a salesman in Tigard, Ore., who has been on several other medications. "My blood sugar levels were all over the place, and I'd feel tired, or dizzy, or confused." Lately his sugar has leveled out around 110. The long action does have a downside: Once Lantus is in, it's in, making it hard to decrease insulin levels for an entire day if they get too high.

A blood test called hemoglobin A1C can tell diabetics how well they are doing at keeping their glucose and insulin on an even keel. "It's the single most useful test there is," says Jackson. Basically, it gives you an average, in one number, of blood sugar levels over the previous three months. "This is the test that, given four times a year, can show you whether you have a higher or lower chance of future problems." Roberson says that "back in February I had a score of 8.1. Then, after I started walking and eating better, it was 7.0. So I feel pretty optimistic." A score near 6 is normal.

She is right to be optimistic when it comes to most of the feared complications. But the news about heart disease is grimmer. "Heart disease has proved a lot more stubborn than other complications," says Richard Nesto, a cardiologist at the Lahey Clinic in Burlington, Mass. "Stabilizing blood sugar levels doesn't seem to do enough." Diabetics run two to four times the normal risk of heart disease.

The reasons: Diabetics have stickier platelets–the tiny cell fragments that help blood clots form–than nondiabetics, and poorer blood flow, which increases the chance of blocked arteries. The actual form of those blocks is different as well. In nondiabetics the danger spots are large fatty deposits, called plaques. "But in diabetics, the plaques can be quite small and soft, almost like a pimple," says John Buse, director of the diabetes program at the University of North Carolina School of Medicine in Chapel Hill. "Then they can rupture, causing a clot that can suddenly block the whole artery. So doctors can't just look for large plaques, and the small ones are harder to spot."

The solution, once again, is prevention, and medicine is just beginning to come to grips with the basics. So basic, in fact, that doctors refer to "the ABCs." A is strict attention to the A1C tests. B is for blood pressure control. The guideline for a diabetic is a pressure no higher than 130/80, which puts much less stress on the blood vessels. And C is for cholesterol: levels of LDL (the "bad" cholesterol) should be at or below 100, a much more stringent limit than for most nondiabetics.

Unfortunately, to meet these guidelines "you can end up taking up to 10 pills a day," says Buse. Along with pills like Glucophage, a diabetic may have to take ACE inhibitors and beta blockers for blood pressure and statins to control cholesterol levels. Doctors may also prescribe the newer diabetic medications like Avandia, because they have the added benefit of lowering triglycerides, blood fats that promote plaque buildup.

The cost of living. It gets expensive, but insurance usually does pay for most diabetic care. For many patients the real challenge is managing it all. "Obviously it takes doctors a lot of time to instruct patients in such a complex regimen, and docs are pressed for time," Buse says. Andrea Levine remembers that the doctor who first diagnosed her spent all of 10 minutes telling how to control the disease.

Just two weeks ago, researchers at the Washington Hospital Center in the nation's capital released a nationwide survey of 200 primary care physicians and the care given to their diabetic patients. Only one quarter said cholesterol testing was important, and just 5 percent mentioned blood pressure. A full third acknowledged they didn't have enough time to talk things through.

That leaves patients with the responsibility for learning about diabetes–about food and exercise and the meaning of a number of tests and early warning signs of low blood sugar or vision trouble. They also need to be aware of the effects of a wide variety of drugs and to watch for new drugs, such as inhaled insulin, that may soon be approved. "You have to learn," says Gabriel Caro, 28, a Boston-based Web designer with diabetes. "Because the alternatives are just too terrifying."