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."