American Epidemic-Diabetes

American Epidemic-Diabetes - An American Epidemic Diabetes...

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Unformatted text preview: An American Epidemic Diabetes The silent killer: Scientific research shows a ‘persistent explosion’ of cases —especially among those in their prime BY JERRY ADLER AND CLAUDIA KALB SOMETHING TERRIBLE WAS HAPPENING to Yolanda Benitez’s eyes. They were be- ing poisoned; the fragile capillaries of the retina attacked from within and were leak— ing blood. The first symptoms were red lines, appearing vertically across her field of vision; the lines multiplied and merged into a haze that slnit out light entirely. “Her blood vessels inside her eye were pop- ping," says her daughter, .lannette Roman, a Chicago college student. Benitez, who was in her late 40s when the problem be- gan four years ago, was a cleaning woman, but she’s had to stop working. Afler five surgeries, she has regained vision in one eye, but the other is completely useless. A few weeks ago, awakening one night in a hotel bedroom, she walked into a door, set- ting off a paroxysm of pain andnausea that hasn’t let up yet. And what caused this ca- tastrophe was nothing as exotic as pestio cides or emerging viruses. What was poisoning Benitez was sugar. Heredity Genes help determine whether you’ll get diabetes. In many families, multiple generations are struck. But heredity is not destiny— especially if you eat well and exercise. Benitez is a representative victim of what many public-health experts believe will be the next great lifestyle~disease epi- demic to afflict the United States: diabetes. (Technically, type-2 diabetes, which ac- counts for 90 to 95 percent of all cases.) At five feet one and 140 pounds, Benitez is overweight; 85 percent of all diabetes suf- ferers are overweight or obese. She was born and reared in Mexico; Hispanics and blacks are more likely to contract diabetes than Caucasians. As the American popula— tion becomes increasingly nonwhite and obese, the disease is rapidly spreading. A study by doctors from the Centers for Dis- ease Control and Prevention startled peo- ple last week with the finding that the prevalence of diagnOsed cases of diabetes increased by a third (fi'om 4.9 to 6.5 per- cent) between 1990 and 1998. But demo- graphics explain only part of this “persistent explosion” of cases, says Dr. Frank Vinicor, director of the CDC’s dia- betes division; even among Caucasians— even those of nonml weight—the rates are on the rise. The actual number is almost surely higher, since many cases go undiag- nosed for years. But the most alarming statistic in the CDC study was the breakdown of cases by age. For people in their 40s, the inci- dence of diabetes increased 40 percent over the eight years; for people in their 30s, it went up nearly 70 percent. “It’s be- coming a disease of the young,” says Dr." Arthur Rubenstein, a leading endocrinol- ogist and dean of the Mount Sinai School of Medicine in New York. In that light, Roman is an even more significant exam- ple. She is only 18, and she has type-2 di- abetes, too. In fact, until recently the disease Ro- man and her mother have was known as adult-onset diabetes, because it usually 1 1343! were in 44.3 sail-5 mm «It? SOURCE: CENTERS FOR DISEASE CONTROL AND PREVENTION struck people middle-aged or older. The other kind was “juvenile” diabetes, now called type 1, which is an entirely different disease altogether. But in America, getting fat is no longer a prerogative of adults, and diabetes, which is strongly linked to obe- sity, is spreading down the age ladder. The rise in type-2 disease among teenagers is “extraordinarily worrying,” says Ruben- stein, because diabetes can take decades to reveal its most appalling effects—includ- ing ulcerating sores, blindness, kidney fail- ure, strokes and heart disease. “If people become diabetic at age 10 or 15 or 20,” he says, “you can predict that when they are 30 or 40, they could have terrible compli- cationsiiYcu can also predictthat they are going to need a lot of expensive health care; on average, medical-care spending for diabetics runs $10,000 to $12,000 an- nually—three to four times higher than on healthy people, every year for life. A num- ber of promising new drugs and therapies may make diabetes easier to live with, but it will be a medical miracle if they end up saving money. We’re Living Dangerously m la: "catch a quarter .itné‘ .i T‘lilrtlt-‘l l. .5. .‘rtltllts repute: m ‘ phi w ill il:'li‘.‘ll,f,, ‘tl am Hilly! i, gt! '. :‘H llillr an H: .I‘xi "ll " .: .. . 25.9% w K‘s-,utu‘u M! l3 «mi “27.5 - an in Us And Paying a High Price in tutti. Uliiyas‘ttii «sum lml ifitrfiii’; mu:- :m-i Lita“ Ila. ltfilflimlt fitr “iillfif‘h‘ilnlfl'l «.llli’rl EMF; 9 --s:. 7 Tun marry salt-rises and it": liltia' mm. m: an: tln: let‘s resin. lecture 35m it l‘iL' diabetes. {metre w pic-term lfliFlCl’lpll‘ with type J iii-alien‘s nnwnemrigiir The [art militari- ul Munro's!“- “l?” air tilliullll‘llfll Mimi-4:. tu turgid; 3H [s unaniw m cm sighs. Elm 9;: mrwl. is sent is . 4. «m n» u nu Luzulll u filming the Min. tin: glrrtnlrtmr HI lute-l klh‘llflilt“ munfird “5 {We unseen", «ml by iil‘l-u uniting; insignia: m tln'ir :it‘ls. Utah-sits mm all-.115 if! uullmu Arugultuiis- i'} gm 2 :lzslmlw lute nus-n in all flung-tr mimic: gnaw-4: H h; t ‘si 12‘. ‘ $.45. 0‘ Age It usually strikes after 40, but " new data shows a dramatic rise among people in their 30s. Children are now being diagnosed with type 2 as well, sounding alarms about the nation’s long-term health—and making the term ‘adult—onset diabetes’ obsolete. Diabetes is a disorder of the very engine of life, a subtle calamity at the molecular level. Its hallmark is a failure to metabolize glucose, the ubiquitous sugar molecule carried by the bloodstream to fuel every part of the body. Deprived of their prime energy supply, muscle and nerve cells slow their function, which is why early diabetes may manifest itself as lethargy and irrita- bility. That was the experience of Maria DelMundo, 46, a Rochester, Minn, mother who weighed around 190 (she’s 5 feet 2) when she stopped by her doctor’s office for a checkup in 1991. “I just wasn’t feeling Mm: «suite: lead iiinlwtt'srntn met Me: In NW l‘is Him. {3 «Mltsx [If-Mill His-I lim Ml i7?“- sltuni rubs I'l-ll-z'Jdillig dialing-s 5:. 5-H mum [let u JI. ’liu‘ ll!lJ.l mutiny inrlmlmg unlmx. C out}, i», 13‘)?- Sicilian ‘éi'n x ‘; l'ttsl 119:1" [I I it; “ ! 1“ t Allul‘rr _ Ill? SOURCES: CDC. NIH, BRFSS REX RYSTEDT. SCIENCE PHOTO LIBRARYWPHOTO RESEARCHERS (INSET) good—tired and out of sorts,” she recalls; in effect, she was undernourished even while eating heritillrof ther‘fbutteryr icing and whipped cream, French pastries and Haagen-Dazs” she loves. At the same time, glucose accumulates in the patient’s blood, and can reach con- centrations two to three times normal and even higher. The excess is eventually ex- creted by the kidneys, which require copi- ous quantifies of water as a dilutant. That’s how Keith Wein, 42, a mechanical engi- neer from Irvine, Calif., caught his diabe- tes-—or, rather, his wife, Michelle, did. “I thought something was wrong when all of a sudden he started drinking water non- stop,” says Michelle, a nutritionist. “He would come home from the grocery store with six or eight bottles of Crystal Gey- ser"—and spend a corresponding amount of time going back and forth to the bath- room. But these are subtle signs easy to overlook or deny. Steven Mallinson, a strapping six-foot, l90-pound hiker and cyclist, discovered he had diabetes at the age of 25 when he enrolled as a paid partic- ipant in a research study of a new drug, un- related to insulin. The drug company took one look at his blood and urine samples and kicked him off the study, telling him to call his doctor immediately. “That’s one of the problems,” says Dr. Richard Hellman 2 of the American Association of Clinical Endocrinologists. “A lot of people are W walking arede withrreither diabeteser a predecessor [condition] and they’re not even aware of it. The symptoms are not specific, and they tend to come late.” Race African-Americans, Hispan- ics and American Indians— who have the highest rates of type 2 in the world—are at greater risk than Cauca- sians. Still, no one is immune: the prevalence of the disease has increased across all racial groups over the last decade. Researchers are still investigating all the ways in which high blood-sugar levels do damage. One obvious effect is on the ar- teries, especially in the eyes, kidneys and extremities; sugar seems to both weaken the capillary walls and clog the small ves- sels. Hemorrhages destroy the retina; im- u; unfit}; W-minrmu rimiwzmii kwxix, [in uflw. 933' much Iii]?! EM - u: Ilium: en: aw 9mm: gnml‘ wmms m m": pmnmmx. mi 5-1» $155: II "mitt wumi ‘13: gm whenwmmmmwNaming; kindh‘f‘g‘i-Hsfi.“ 611mm; minim: In {Semi-95 as:th mg: 'I,- Elamm wake. m1 26m! ’ e:. A :h, III? (“I m [‘1‘ AI"! -3 damn: quafil} ’7 was. m nri'msi , m min-{mink n: mu: m: ,ln’n'i'a ’ rm mm; : .Iu» 95:5,? up 1:: Iln in ml «011m, xhwm m; nu! ImlT'sN'Imfcl n‘n'gr Mn nu u hunky-«a hmmnr I43 an: m SSIIHL‘C'fi-lfu 1131:. kill“ gm; '«J-K‘lf! mafia i Im-‘uh’u-I °" xzm‘l uric-n ( ~ gmflzfla. savaIuI E4- 53’»: .3 &I“IIVHTEII1£' I SOURCES: AMERICAN DIABETES ASSOCIATION, CENTERS FOR DISEASE CONTROL AND PREVENTION, THE GLUCOSE REVOLUTION, NATIONAL INSTITUTES OF HEALTH RESEARCH BY MEREDITH SALISBURY, GEOFFREY COWLEY, AND SUSAN RAINEY. GRAPHIC BY DONGMIN SHIM AND KEVIN HAND~NEWSWEEK when (this. rust (fists-ist- mm': L‘fltFP iiialmstxm “iii chock. clmupz. nr insulin rim help. 11m: an: an titul‘ dams-3*» ufmealiustit ms: 52W Drum itin- (iluu utml prmupt lunrrtnlit‘ rails in ittluit‘ Maura: insulin W [Elm uphugc‘ and rrlalml treat- ment-s help {nah (cits m- m.- rvspz assist: m L}. minim.“ insulin in: prewar In tin: lust} Gum Mm l‘l‘irrnsx' and (felt an lit‘lp [13K]? km" hl'mniasugur Irwls: li-‘j; dummy; tit-r inexh- slmwn {llii'ill‘illiljflllHit}? is! :ilt: ding-iii“: (mail ’L’ Mm il miles?- diaaluvs can tagger .1 startling: army firms umliml pmlils‘mtt. Eyes 3 Jlall‘k'lk‘i N tlw liming ram-93 I ll rims {mm r it" liiimilv- HEEE-v' m {mink If} E) 74 w Nearly lizsll‘ulum'n mun-a Island-5tng Heine} Ilia-rm» sum i‘lfilsl assume * "8m l Faults‘swufli‘rmn in lrutt‘timrr~ tilt: IMME mu: nlvmr iii: Annular (la-cuss! («this l‘"i~,»,'»;_lit pertain: [sitar- lxax: 5min trulng lino: Ilzl§ml£flufl3 W .‘i'iust tlmltsnu sufl‘u "yaw timings. and ms. “quitting is}; .‘mtgnuan l'et- KIM KULISH—SABA paired circulation leads to ulcers in the legs and feet for which amputation may be the only cure. The risk of heart disease doubles for men; for women it goes up fourfold. Yet the misperception of diabetes as a rel- atively benign condition persists. “The word is not yet out about how serious it is,” says Anne Daly of the American Diabetes Association. “There’s no diabetes that’s not bad. It’s all serious.” Glucose metabolism is regulated by the hormone insulin, which is produced by the pancreas gland, a fist-size clump of tissue behind the stomach. In normal people, the pancreas secretes insulin in response to a rise in blood sugar, which happens after a meal. The relatively uncommon type-l di- abetes is marked by a straightforward shortage of insulin, which typically shows up around puberty. Researchers consider this an autoimmune disease, possibly brought on by a viral infection. And the treatment is straightforward in concept, if not always in practiceryou supply the missing insulin, if necessary by injecting it before meals. Although the name “juVC- nile” diabetes has stuck, it’s a disease you have for life; luckily, though, there’s no evidence that its incidence is on the rise in the United States. Type 2 is an altogether more compli- cated disease, a spiraling derangement in a network of positive and negative feedback loops linking the pancreas, liver (which 4 stores and releases glucose), muscles, nerves, fat cells and brain (the only organ capable of deciding not to open a pint of rum-raisin ice cream). Perversely, the muscle cells refuse to absorb glucose from the blood, a phenomenon called insulin re- . ,sistance. At leastin theearly stages of the disease, type-2 diabetics usually have nor- mal insulin production. In fact, they may have above-normal insulin, as their pan- creas produces more and more of it in a fu- tile attempt to keep up with the rise in blood sugar. Over time, though, people may need more insulin than their pancreas can supply, and these patients, too, oflen become dependent on injecting themselves with insulin. Helping to Break Bad Habits Present danger: Why so many people ignore doctor’s orders and put their lives at risk. IT SOUNDS SIMPLE. WITH PROPER ATTEN— tion to blood sugar and diet, a person with diabetes can go a long way toward staying healthy. But it’s not simple. Many people with diabetes risk illness and even death by leaving their disease untreated. The vast majority of people who are referred to the diabetes center where I work have excel— lent access to health care and good doctors. Yet their diabetes is out of control. A 5 8—year~old executive came to my of~ flee several years ago, referred for what his primary—care doctor called “noncompli— ance with his diabetes regimen.” The pa~ tient was at least 20 pounds overweight, he did not follow his diet and he rarely checked his blood sugar, saying he didn’t understand how and when to do it. His wife nagged him so often about his health that he called her the “chief of the diabetes po— lice force He came to my office unwilL ineg and feeling sheepish, the way people do when they intend to go to the gym but never get around to it. Ignoring diabetes may seem as irre— sponsible as smoking cigarettes or driving drunk. But in many ways it’s more under- standable. For one thing, the disease moves so slowly that people with diabetes ofien feel perfectly fine. About one third of those with type—2 diabetes—more than 5 million people~don’t even know they have it. BY ROBIN S. GOLAND, M.D For those who know or suspect they have diabetes, denial can be a powerful ob— stacle to treatment. Because diabetes has genetic roots, many people at risk have al‘ ready watched a relative go blind or lose a leg. Not knowing mat treatments have im~ proved dramatically over the past decade, these people assume, wrongly, that such complications are inevitable. Patients have asked me, “What’s the point of giving up the food I love if I’m going to go blind any— way.” Then there’s the intimidating prospect of a lifetime of vigilance. To properly care for their disease, people with diabe— tes may have to check their glucose be- tween sets of tennis. Or excuse themselves from a business meeting to eat a snack. Taking care of diabetes “is not for an hour, it’s not for a week, it’s not just for Wednesdays,” a patient once told me. “Diabetes never takes a vacation.” The relentlessness of the regimen creates in many a sense of isolation and fatigue. When no one else in the restaurant needs to worry about health when the food is slow to arrive, staying motivated to care for the disease gets harder and harder. To make matters worse, people with di— abetes get insufficient support from the US. health—care system. Diabetes centers around the country are closing because many insurers do not reimburse for pre— ventive treatment. And many doctors, with their growing caseloads, don’t have time to give people with diabetes the attention they need. Too oflen they tell patients to lose weight or get more exercise Without ensuring that real lifestyle changes are tak- ing place. People with diabetes need more than preprinted menus and one—time lessons in finger pricks. They need long—term, indir Vidualized educational and nutritional counseling. Not only do people with diabe— tes need to learn the difference between an English muffin and a bagel; they need to learn about various glucose meters and medications—and then get comfortable using them. And then there’s the matter of long—term maintenance. Some people man— age diabetes well on their own. But others need ongoing attention and an understand— ing ear when they fall ofl" the wagon. There’s good news, though In the three years since he visited our center, that 58— yearpld executive has brought his blood— sugar level down to normal. He’s stopped gaining weight and has no complications from diabetes. Now he’s telling his friends and family that while treating diabetes is no fun, it’s doable in an active, healthy life~»—and it’s better than the consequences of ignoring it. What could cause such a devastating misreading of biochemical messages? In— evitably, genetics seems to play a role. Just last week a team at the Whitehead Center for Genome Research identified a variant form of a gene on human chromosome 1 that appears to increase the risk of type-2 disease by about 25 percent—although it’s carried by as much as 85 percent of the population, so having it doesn’t seem to be cause for any special alarm. Certain popu- lation groups are especially prone to diabe— tes; among the Pima Indians of the Southwestern United States half of all adults suffer from it. Living in a harsh cli- mate where food is naturally scarce during much of the year, they may have inherited a so-called thrifty gene that lowers metab- olism in times of famine, at the price of in~ creased susceptibility to diabetes. But it took the United States, land of the 40- ounce soda, to elevate that susceptibility to a crisis; the closely related tribe of Pimas in Mexico who farm and eat a traditional diet don’t have nearly the same rate of dia— betes. The correlation between type-2 dia- betes and obesity is overwhelming: 13.5 percent of obese patients in the CDC sur- vey had the disease, compared with 3.5 percent of those of normal weight. “As people get fatter, the risk of diabetes goes up dramatically,” says Vinicor of the CDC. The exact nature of the relationship is ex- traordinarily complex and poorly under- stood, but the simplest way to think about it may be that for unknown reasons, the 5 same things that make you fat also put you at risk for diabetes—lack of exercise and a high~calorie diet. The very complexity of the glucose insulin cycle, though, affords numerous oppornmities to intervene with therapies. The obvious therapy, of course, is insulin. For years the only available form was har- vested from cows or pigs, but now human insulin is being manufactured directly by recombinant DNA techniques. And not just insulin—drug companies are coming out with new and improved insulin, engi— neered with molecular changes to make it last longer in the body or be absorbed more easily into cells. Until recently, insulin had to be injected under the skin as often as five to seven times a day, in a complex cal- culus of food intake, energy output and dosage designed to keep blood sugar fi'om going either too high or too low. Howard Mitchell of Bangor, Maine, 46, who weighs 280 pounds and is a type-2 dia- betic, wears an insulin pump like a beeper, Are You at Risk? Because type-2 diabetes causes no symp- tomsatfirsgitofiengoesunmanagedfor too long. Some possible warning signs: - Frequent urination - Constant thirst or hunger - Blurred vision - Numb or tingling extremities ' Frequent skin infections ' Slow healing of cuts and bruises Getting Tested When people have symptoms, or clear risk factors, physicians use two basic tests to diagnose type-2 diabetes - Fasting test: Blood glucose should be below llOmg/dl after an overnight fast - Oral tolerance test: Blood glucose should not be higher than 140mg/dl two hours afierthe patient swigs a cup of glu— cose—laden fluid which he can program to deliver a mea- sured dosage whenever he needs it. Now, he says, “my life is no different than any- one else’s.” An implantable version may be available soon; someday a completely self—contained unit may be able to measure blood ghicose directly and deliver insulin automatically. Other drugs, such as the sulfonylureas, which have been around since the 19508, stimulate production and release of insulin by the pancreas; many type-2 diabetics take some form of these. But newer drugs, some introduced within the last year or two, offer far more possibilities for con- trol. Glucophage is one; it controls blood sugar directly by promoting glucose stor- age in the liver. A class of drugs called TZDs make muscle and fat cells more sen- sitive to insulin, combating type-2 disease right at the source. And there are drugs that work in the gut to inhibit starch digestion, slowing the process enough to flatten the glucose “spike.” “All these are new devel- opments since 1995,” says John Buse, di- rector of the diabetes center at the University of North Carolina at Chapel Hill. “There’s 255 different combinations of drugs, insulin, exercise and diet modifi- cation; I probably use 245 of them in my practice.” But there’s another surefire way to con- trol blood sugar and lessen the complica- tions of diabetes; it calls for eating a healthy diet in the first place. , theme in the conversations of diabetics is the foods they had to give up. Maria Men- doza, a college janitor in Los Angeles, cut down from “six or seven tortillas a day” to two after she was diagnosed with type-2 diabetes in 1985, and gave up “tacos, sweets, chocolates and pan dulce [sweet bread].” “I can’t eat what 1 want, and that makes me sad,” she says. “At times, I feel so deprived 1 want to cry.” But increas- ingly, doctors have come to believe that an absolute ban on refined sugar is too restricn tive. With conscientious monitoring of their blood sugar, regular exercise and the right attitude, many diabetics can now al- low themselves an occasional sweet. Pro- vided,ofcourse,itispartofthe same low- fat, high-fiber, low-calorie diet that re- searchers recommend for just about every other major problem in American public health Sophisticated patients don’t just stick to a diet: they monitor what they eat obsessively, and plot it against blood-sugar levels that they measure themselves (with a blood-glucose meter and a drop of blood from a finger) as often as five times a day. “My goal is to keep my glucose level under 150,” says Michael Negn'n, a 41-year-old New York businessman (The number re- fers to milligrams of glucose per deciliter of blood.) “Yesterday I woke up and it was 179. I took my medicine and ate breakfast, and it went down to 122. Afier lunch, a corned-beef sandwich, I went up to 156. I worked out in the evening, and l was down to 58.” Evidence is also accumulating that the lack of exercise contributes to diabetes. Dr. Alan Shuldiner of the University of Mary- land has been studying Amish families in Pennsylvania, who have about half the rate of diabetes found in the general Caucasian population—even though their diet is no healthier and the adults are just as likely to be fat. What sets them apart is that they don’t have cars; when they’re not riding a buggy, they’re on scooters or roller skates, r ~and(without telephones} they spend a lot of time going back and forth just to chat. And, says Shuldiner, with the absence of television, “you never see obese Amish children. Never.” It’s a tough prescription, and the doctor hasn’t been born yet who could get Amer- icans to live like the Amish—even with those great pretzels and shoofly pie. But somewhere between the contemporary lif- estyle and the 18th-century one there has to be a happy medium that can let us enjoy our food and comforts—and avoid the coming scourge of poisoning by sugar. With KAREN SPRINGEN in Chicago, ANA FIGUEROA in Los Angeles, JOHN LAUERMAN in Boston, JOAN FELICE RAYMOND in Cleveland and ERIKA CHECK, HEATHER WON TESORIERO and SUSAN RAINEY in New York __—____—_—_—_—————-—————-———— From Newsweek, September 4, 2000, pp. 4047. O 2000 by Newsweek, Inc. All rights reserved. Reprinted by permission. ...
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American Epidemic-Diabetes - An American Epidemic Diabetes...

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