The Highs and Lows of Managing and Treating Diabetes

According to the Centers for Disease Control and Prevention (CDC), one in every three Americans will develop diabetes in their lifetime; it is currently the sixth-leading cause of death in the U.S.¹ But America is not alone: In 2008, there were an estimated 246 million people with diabetes worldwide, and the World Health Organization (WHO) expects this figure to rise to 370 million by 2030.²

A stealthy and insidious illness, diabetes currently affects in excess of six million people who are asymptomatic and unaware they have it, making the disease that much harder to track and treat. Additionally, it is estimated that more than 40 million Americans can be classified as “pre-diabetic,” meaning they have blood sugar levels higher than normal but still below the prevalent type 2 diagnosis level. As for direct healthcare costs, U.S. estimates have skyrocketed to nearly $116 billion annually.³ Many public health authorities say diabetes cases have now reached epidemic numbers, demanding urgent and focused research aimed at prevention and treatment, and ultimately identifying a cure. For families impacted by this lifealtering disease, the increased focus and attention could not come a moment too soon.

“Our son, Andy, was diagnosed with type 1 diabetes when he was 10,” says Carol Johnson, an Indiana mother of three. “I recognized the symptoms right away — extreme fatigue and excessive thirst — because Andy’s uncle died from diabetesrelated complications at the age of 24. When the doctor confirmed what we suspected, we were devastated.”

Because the Johnson family has a history of diabetes, genetics and environmental factors are both suspected culprits in Andy’s diagnosis. Now 18 and on an insulin pump, Andy faces an uphill battle in managing his health, and as a college-bound youth, is tasked with avoiding the insulin-spiking foods that are a ubiquitous part of dorm life, while also tracking his daily insulin levels without mom or dad around to remind him.

“I’ve been managing my treatment almost from the beginning, so I feel pretty confident about doing it while away at college,” says Andy. “The hardest part has always been psychological; nobody, especially a kid, likes to be viewed as different.”

One Disease, Three Disease States

When we eat, food is turned into glucose, or sugar, which our bodies use for energy. In a healthy individual, the pancreas produces the hormone insulin, which transports glucose into the cells, where it can be used as fuel. In a person with diabetes, the body makes too little insulin or is unable to use the insulin it makes effectively. The result is excess sugar in the blood, which is sometimes referred to as “high blood sugar.” The term diabetes is often used as an umbrella term to describe chronic high blood sugar, but there are actually three specific disease states:

• Type 1 diabetes, also called juvenile diabetes, is an autoimmune disease that is typically diagnosed in childhood. With this disease, the body makes little or no insulin and patients require daily insulin injections. The cause of type 1 diabetes is unknown, but genetic and environmental factors are suspected links.
• Type 2 diabetes makes up the majority of diabetes cases, typically striking in adulthood, although rates are increasing among children and adolescents. With type 2, the pancreas does not make enough insulin to keep blood glucose levels normal, often because the body does not respond well to insulin. Many people with type 2 diabetes do not know they have it. Type 2 diabetes is associated with obesity, poor diet and irregular exercise, and is potentially preventable and manageable with lifestyle changes.
• Gestational diabetes is high blood glucose that develops at any time during pregnancy in a woman who does not already have diabetes.Women who have gestational diabetes are at high risk of type 2 diabetes and cardiovascular disease later in life.

Weighing In on the Obesity Link The connection between excess weight and type 2 diabetes has been well-established. A 2009 Loyola University Health System study revealed that 62.4 percent of U.S. adults with type 2 diabetes are obese, and 20.7 percent are morbidly obese.⁴ Among African-American adults with type 2 diabetes, one in three is morbidly obese. “The rate of morbid obesity among people with diabetes is increasing at a very alarming rate, and this has substantial public health implications,” says Dr. Holly Kramer, a kidney specialist and lead author of the study published online in the Journal of Diabetes and Its Complications.

Researchers also suspect rising childhood obesity rates of being at the root of the epidemic number of children being diagnosed with type 2 diabetes. But, despite ample evidence regarding the link between obesity and diabetes, exactly why millions of overweight people develop the disease has remained somewhat of a medical mystery.

A 2001 study suggested the root cause was a hormone called resistin, which is produced by fat cells and incites tissues to resist insulin. However, in 2003, scientists debunked this theory in findings published in the Journal of Clinical Endocrinology and Metabolism that showed no correlation between resistin levels and body mass index, lipid profile or insulin resistance levels.⁵

Other studies connect the type of obesity (where fat is stored) with risk levels. Those who store it around the middle (the socalled apple shape) are at higher risk of developing diabetes than their pear-shaped counterparts. And, some nutritionists believe that high-carbohydrate, low-fiber diets are also part of the problem. Finally, because exercise makes your body’s muscle cells more sensitive to insulin, a sedentary lifestyle is considered a diabetes risk factor.

Lifestyle Changes Versus Surgery

Most physicians encourage lifestyle changes for patients with type 2 diabetes, including a healthier diet and regular exercise, but some are now saying that a last resort for morbidly obese diabetics may be bariatric weight-loss surgery. Scientists have discovered that diabetes all but disappears in some obese patients soon after the operation, and for many patients, weight-loss surgery can eliminate the need for diabetes-related medications.

In February of this year, the Harvard-affiliated Joslin Diabetes Center and Brigham and Women’s Hospital announced plans for a clinical trial comparing weight-loss surgery and weight-management programs for the treatment of type 2 diabetes. The two-year study will examine whether patients test in the non-diabetic range for one year after either the surgical or medical and weight-management interventions. Previous observational studies estimate that 60 percent to 90 percent of bariatric surgery patients who were obese and had type 2 diabetes were later able to maintain normal blood glucose levels without medication.⁶

“Weight-loss surgery has become a go-to option for obese patients with type 2 diabetes because of the successes seen,” says Dr. David Lautz, director of bariatric surgery at Brigham and Women’s Hospital and instructor at Harvard Medical School. “We want to compare these popular procedures with particular lifestyle-modification and medical-management programs to determine more scientifically what the most effective option is, particularly for the less overweight patient.”

The Cleveland Clinic’s Bariatric and Metabolic Institute is hosting a similar study among 150 overweight and obese type 2 diabetics, some of whom will have surgery. Their progress will be compared with the progress of those who manage their diabetes with medicine. The goal is to see which group can achieve complete remission.

At this point, doctors are unsure how weight-loss surgery helps diabetics, but there is some evidence that it may not all be due to weight loss. Diabetes occurs when the body is unable to regulate blood sugar, and some researchers think that the rerouting of the digestive tract after the operation affects the gut hormones involved in blood sugar control. Currently, the American Diabetes Association states there is not enough evidence to generally recommend surgery for diabetics with a body mass index (BMI) lower than 35, outside of an experiment.

Research Yields Promising Treatment Options

The main goal of diabetes treatment for both type 1 and type 2 patients is to keep blood sugar levels as close to normal as possible. Treatment options usually involve changes to the person’s diet, weight-loss recommendations and an exercise regimen. Medication such as insulin shots, inhaled insulin, injected medicines that improve the release or use of insulin, or oral medication also may be prescribed. Additionally, diabetics need to get regular screening tests to rule out potential health complications.

Today, much of diabetes research is focused on the development of improved insulins that will better mimic natural insulin secretion. Other developing technology includes more efficient personal insulin pumps and monitoring systems; gene therapy; pancreas transplants; and even the use of an artificial pancreas. Each of these approaches still has drawbacks, but progress is being made. Speakers at a 2010 joint American Diabetes Association/Juvenile Diabetes Research Foundation (JDRF) symposium at the association’s 70th Scientific Sessions said in a news release that the development of an artificial pancreas to effectively control blood glucose levels in children and adults with type 1 diabetes continues to make rapid advances. Those in the field predict that technology of this kind could become commercially available within the next few years.⁷

“We’re all interested in people with diabetes achieving better glucose control,” says Aaron Kowalski, PhD, research director of the Artificial Pancreas Project. “The community needs to hear what’s happening and where we are headed.”

The diabetes epidemic also has resulted in a push to create more efficient monitoring devices for patients.In the past, diabetics had to regularly test their urine to keep track of blood sugar levels; today, most diabetics use blood glucose meters to monitor them. With a typical glucose meter, the patient places a small sample of blood on a disposable test strip and then places that strip on the meter. The glucose in the blood adheres to chemicals on the test strip, and the meter measures how much glucose is present. After a blood glucose reading is done, the patient is responsible for administering insulin, if needed.

Insulin administration can be done through a syringe, an insulin pen, a jet injector, an insulin port or an insulin pump. From a lifestyle perspective, insulin pumps offer a tremendous amount of freedom and improved patient compliance, since they can deliver insulin 24 hours a day through a catheter inserted under the skin. The patient wearing it can order the pump to deliver extra insulin at meals or other times when blood sugars may be higher than usual. New technology also links meters and pumps wirelessly, which means patients don’t have to calculate and enter the correct amount of insulin into the pump. Carbohydrate counts and other data collected by the meter can be uploaded to a computer and printed out and given to a healthcare provider, improving accuracy of care recommendations.

An Ounce of Prevention

Not all diabetes research is focused on the treatment of those who are already sick. Keeping people healthy through education and intervention is also an essential weapon when it comes to fighting diabetes. Statistics show that prevention or delay of type 2 diabetes is possible in some patients who are pre-diabetic. According to a diabetes fact sheet published by the CDC:⁸

• Progression to diabetes among those with pre-diabetes is not inevitable. Studies have shown that people with prediabetes who lose weight and increase their physical activity can prevent or delay diabetes and return their blood glucose levels to normal.
• The Diabetes Prevention Program, a large prevention study of people at high risk for diabetes, showed that lifestyle intervention reduced developing diabetes by 58 percent during a three-year period. The reduction was even greater (71 percent) among adults aged 60 years or older.
• The benefits of interventions to prevent or delay type 2 diabetes are both feasible and cost-effective, since lifestyle interventions are much more cost-effective than long-term use of prescription medications.

In addition to its extremely high psychological and economical price tags, the consequences of undiagnosed or untreated diabetes are many. Even with improved medications and treatment protocols, those with advanced diabetes are at risk of blindness, amputations, renal (kidney) failure, blood circulatory problems, heart disease and strokes. Diabetics also are at increased risk of developing serious complications from viral infections like influenza. In fact, the rate of complications from diabetes is high, according to a report released by the American Association of Clinical Endocrinologists titled “The State of Diabetes Complications in America.” The report showed that nearly 60 percent of people with diabetes have at least one of the complications caused by long-term failure to control the high blood-sugar levels tied to the disease.⁹

No Quick Fix

The diabetes epidemic did not happen overnight, and it will not be a quick fix, despite increased education, intervention and prevention efforts. Controlling both type 1 and type 2 diabetes requires a high degree of patient involvement and compliance, coupled with behavior modification and lifestyle changes that often prove challenging to implement, especially among younger patients. For 18-year-old Andy Johnson, it comes down to accepting personal responsibility for tracking and treating the symptoms of diabetes on a daily basis. “I learned pretty early that this is my disease and I have to take responsibility for it,” he says. “Becoming independent means that if I want to stay healthy, I can’t look to my parents or the doctors to monitor my [insulin] levels or watch what I eat. It really is up to me.”