Diabetes 'Revolution' is Cutting Both Ways

Diabetes expert John Buse recalls looking into his office's waiting room in the early 1990s and seeing it filled with people suffering the long-term complications of the disease. They would be blind, have legs missing from emergency amputations or be on kidney dialysis.

Not anymore.

Diabetes rates continue to skyrocket, but "most days in the clinic, I see no one disabled with diabetes," Buse says. "No one."

The Centers for Disease Control and Prevention reported this month that the prevalence of heart disease dropped 14 percent in diabetics ages 35-64 from 1997-2005. Since the mid-1990s, rates of other complications such as diabetic kidney failure, blindness and deaths caused by a lack of insulin have declined, the CDC reports. It reflects what Buse calls a "revolution" in diabetes treatments during the past decade.

That's the good news. The bad: Not everyone is reaping the benefits. Heart deaths have declined in men with diabetes, but not in women; kidney failure rates among diabetics are much higher in blacks and Hispanics than in whites. Meanwhile, the disease is increasing worldwide at such an alarming rate that the number of new cases is outpacing the number of those benefiting from gains made in treatment. That's largely because obesity, the chief risk factor for the most common form of diabetes, is a growing problem.

Diabetes, caused by the body's inability to produce or use insulin effectively to prevent a buildup of sugar in the blood, now afflicts nearly 21 million in the USA and roughly 250 million worldwide. Health analysts project that by 2025, 50 million Americans and up to 380 million people globally will have diabetes. So even as treatments for diabetes complications improve, the disease's rising prevalence means there will be more people disabled by it and more who eventually will die from it.

During the past decade, medical studies have shown that by reducing high blood pressure and cholesterol and keeping blood sugar levels as close to normal as possible, diabetics can forestall many of the disabling complications that once seemed inevitable. This knowledge, along with simpler, more accurate blood tests and better drugs, has improved treatment, says Buse, an endocrinologist at the University of North Carolina at Chapel Hill.

But the soaring rate of people with diabetes threatens to overwhelm health systems and undermine economies, health specialists say. The problem has mobilized world health leaders, who are marking World Diabetes Day on Wednesday to draw attention to the issue. For the first time, the United Nations is taking part in such activities and has passed a resolution encouraging member states to develop national policies to prevent and treat diabetes.

The International Diabetes Federation, which tracks global diabetes, says the disease will cause 3.8 million deaths worldwide this year, nearly equal to HIV/AIDS and malaria combined. In the USA, the CDC says, it is the sixth leading cause of death, contributing to nearly 225,000 deaths in 2002, up from 213,064 in 2000.

"The prevalence of diabetes is going up because obesity is going up," says Judith Fradkin, director of the National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health. "But if we hadn't made the prog-ress we have, things would be much worse."

New drug treatments, more accurate methods for monitoring blood sugar levels and assessing control of diabetes, and practical steps that patients can take are more common than ever, she says.

A Disease With No Respect

Buse, president of the American Diabetes Association, says it wasn't so long ago that diabetes treatments weren't much of a priority in the medical community.

"It was the Rodney Dangerfield of human disorders," Buse says. "Ten or 15 years ago at ADA, we were talking about what message we want to convey (to the public), and a decision was made not to convey the message that diabetes was serious," because there was so little doctors could do to prevent complications.

"It would have been like saying: 'Bad news, your house is on fire, and worse, there's no water for miles,' " he says. Until 1993, it wasn't clear that lowering blood sugar prevented or delayed complications, and it's only within the past decade that doctors learned that managing blood pressure and cholesterol reduced complications, he says. "Until 1995, there had been no substantial advance in drug management of diabetes since the 1950s."

Diabetes, like other chronic diseases, is caused by a combination of genetics and environment. It results in a high level of sugar in the blood, which over time clogs vessels the way gummy oil clogs a car engine, leading to poor circulation that affects everything from brain to feet, increasing the risk of heart disease and damage to kidneys, eyes and nerves.

There are two major forms of diabetes: type 1, an autoimmune disease that results in loss of the insulin-producing cells in the pancreas and usually occurs in children or young adults, who need daily insulin shots; and type 2, which accounts for 90 percent of diabetes cases and is associated with obesity and inactivity and reduces the ability to use insulin efficiently.

American Indians, blacks, Asians and Latinos are believed to carry a higher genetic risk for type 2 diabetes. That, along with increasingly fatty diets, has helped to trigger an explosion of diabetes in those communities — even as treatments for complications from diabetes have improved.

Dorothy Becker, chief of the division of pediatric endocrinology and diabetes at Children's Hospital Pittsburgh, treats children, most of whom have type 1 diabetes.

"I used to see major complications in kids," she says. "Now, I can't make my kids understand what complications are. We used to see kidney damage, now we're not. We used to see protein in the urine (an indicator of decline in kidney function), but now we don't see it at all. We're just not seeing what we used to see."

Doctors say these changes are the result of improvements in:

Diagnosis. Greater awareness of diabetes has prompted increased screening and earlier diagnosis of type 2 diabetes. One example: The Blood Bank of Delmarva, which serves Delaware and the Eastern Shore of Maryland and Virginia, last month began offering free, non-fasting blood sugar tests to donors. Donors will have access to a secure site online to see their results and get more information on their diabetes risks. Those whose tests indicate dangerously high blood sugar levels will be contacted by the blood bank.

Drug treatments. Once, there was a single type of insulin. Now there are six types and several classes of drugs, including those that boost the body's own insulin production, reduce the need for extra insulin or lower the risk of complications. The most recent entries are drugs that act on gut hormones to keep blood sugar levels steady without causing weight gain or hypoglycemia, a low-sugar condition that can be dangerous.

But recent reports suggesting the anti-diabetes drug Avandia increases the risk of heart attack and death from heart disease show that research is needed — not just to find new drugs but to assess the long-term effects of drugs already in use.

"We have validated the concept that lowering blood sugar is good," Buse says, "but we don't have trials that demonstrate using drug X has advantages over using drug Y. And particularly, we don't have proof we can lower the risk of heart disease or stroke in patients who have diabetes using blood-sugar-lowering drugs."

Blood sugar control. A variety of high-tech meters and monitors that measure blood sugar in seconds, along with insulin pens, pumps and jets, have made tighter control much easier. Injected insulin has become so easy to use that a recently introduced product, the inhaled insulin Exubera, was pulled from the market last month because of poor sales.

Diabetes management. Several studies have shown that early, intensive treatment to keep blood sugar, blood pressure and cholesterol under control has lasting benefits, giving doctors science-based ammunition to keep patients on track.

The advances mean that if patients manage their diabetes, the disease doesn't have to impose the limits it once did, says Rita Louard, director of the Clinical Diabetes Center at Montefiore Medical Center in New York.

It took Sandra Velez, 55, of Yonkers, N.Y., several years with diabetes before a family tragedy brought home to her the seriousness of the disease. She has five siblings, including a brother, Felix, 60, who lives with her, and several aunts and uncles with diabetes. Her father, an uncle and two brothers died of complications. And four years ago, her daughter, Stephanie, who also had diabetes, died at 27 of flu-related pneumonia.

Stephanie's blood sugar levels were six times above normal, Velez says, a dangerous condition because diabetes increases susceptibility to infectious diseases and makes them harder to cure. "When she passed, they said if her diabetes hadn't been so out of control, maybe something could have been done."

That was when Velez, one of Louard's patients, began to take control of her own health, though she didn't change overnight.

"I said, 'I cannot continue like this.' I would be sometimes very depressed, say, 'The heck with it, I'm going to have a cheesecake,' " she says. She is 5 feet 4 inches tall and weighed 240 pounds. She took daily insulin shots to control her blood sugar.

Finally she realized, "I was really harming myself." She got an exercise bike and some hand weights. At first, "I used them two minutes and gave up," she says. "But in the last few months, I've been using them every night. I started doing half an hour. Now I'm up to 45 to 50 minutes a night." And she spends her lunch hour walking and window-shopping. The result: Her blood sugar level is in the normal range, and she has lost almost 65 pounds. She still takes medication, but "they took my insulin away."

She watches out for her brother, a former cabdriver, who is having symptoms of nerve damage in his feet. Before she insisted he get a physical exam a year and a half ago, when his diabetes finally was diagnosed, Felix hadn't seen a doctor in 28 years. Now, she makes sure he checks his blood and takes his medicine. "I taught him about diet," she says. "He was upset in the beginning. He said, 'Why can't I eat cake?' But I said it's not my fault."

Fighting Fear With Information

Diabetes itself doesn't kill, doctors say. It's uncontrolled diabetes — the heart disease, kidney failure, nerve damage and increased susceptibility to infection — that causes illness, disability and death.

"Patients are terrified of diabetes and its consequences," Buse says. "Generally, the first step in treatment is to make patients believe that diabetes is a disease that can be effectively controlled. A well-informed patient is generally so highly motivated and the treatments generally so well tolerated that avoidance of complications is a reasonable expectation."

But rising obesity threatens to blunt progress on other fronts, Buse and other experts warn. They say it will take a major societal change of the kind that changed smoking habits to prevent a future of fatter, sicker people.

"I am optimistic, but I do think the problem is going to get worse before it gets better," says Ann Albright, director of the CDC's diabetes division. Prevention is key, but "it's going to take time to get policies in place, and for large numbers of people to be able to access new technologies and diabetes education."

Last month in Seattle, the Pacific Northwest Research Institute hosted a meeting of international scientists who formed an alliance aimed at thwarting what they called a "growing tsunami of diabetes."

The "amount of money it will cost in 10 years to manage diabetes is going to bust the economies" of many countries, says institute president Paul Robertson. "Governments need to jump in and understand, if they don't help, you can pay us now, or pay us later."

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