DIABETES: WHY THE FUSS?

By Andrew Balder, MD

As a doctor, I take diabetes mellitus for granted.  It helps at times to step back and remind myself that this may not be the same for the community.  There has been a lot of noise about diabetes in the medical community the last 10 years, much of it coming in the last two years.  Why is this so?  The numbers (data) speak for themselves, and the science makes it worth paying attention.

DIABETES-WHAT IS IT?  Many people call diabetes “sugar”, and they are mostly correct.  Diabetes is defined and diagnosed by finding an elevated level of glucose (sugar) in the blood.  This may be when someone has had nothing to eat or drink for a while (“fasting” state), or 1-2 hours after eating (“post-prandial”).  Exactly when and how much the glucose is elevated becomes important in deciding the best treatment.  While most people want to blame having diabetes on eating a lot of sugar, this alone is not the cause.  Sugar is continually entering the blood, both from what we make in the body and what we eat.  We make the hormone insulin to tell the body to move glucose out of the blood into places that need it for energy (muscles, brain and other places).  When we cannot make enough insulin to carry this message (“insulin deficient”) or our cells are not able to respond to the insulin’s message (“insulin resistant”), our blood sugar goes up.  Almost all diabetes in adults starts with insulin resistance, but after 10-15 years will also include insulin deficiency.

DIABETES IS COMMON: 17 million Americans have diabetes (more than one in 12 adults).  One third of them do not know it yet.  Closer to home, 2.8 million African American have diabetes (more than one in 8), as do 10% of Latino Americans.  These communities have diabetes at twice the rate of non-Hispanic white Americans.  One quarter of African Americans over age 65 have diabetes.  These rates are growing, along with that in children and teens.

DIABETES LEADS TO OTHER ILLNESS: So what if your sugar is high?  Isn’t it just a number?  NO!  A high sugar itself can make you feel tired, urinate a lot, become thirsty and blur your vision.  If particularly severe it can even lead to coma.  Over the long run, however, it is the slower developing complications that are the real problem.  Long-term poorly or even partially controlled diabetes can lead to:

Ø      Eye disease: blindness from bleeding in the back of the eye.  Diabetes is the number one cause of blindness in America

Ø      Kidney failure: 43% of end stage kidney disease in the USA; 2.5-5 times more likely in African Americans

Ø      Heart attacks: 2-4 times more common than in non-diabetics, diabetes is now called a “coronary disease equivalent” meaning that if you have it your risk of having a heart attack is the same as if you had already had one

Ø      Stroke: 2-4 times more common in diabetics

Ø      Amputation: 60% of all non-traumatic leg amputations are in diabetics; 1.5-2.5 times more likely than in non-diabetics

Ø      Hypertension (high blood pressure): 73% of all diabetics have hypertension

Ø      Erectile Dysfunction

Ø      Dental disease

Ø      Pregnancy Complications: birth defects, fetal death, very large babies

Ø      Deaths: the death rate in adult diabetics is twice that of non-diabetics

DIABETES IS COSTLY: $132 billion was spent on this disease in 2002; $92 billion in direct medical costs, the rest in lost wages and other indirect expenses.

TREATMENT WORKS: Diabetes is treated in many ways, but all of the start with “lifestyle” measures.  Diet and exercise are the cornerstones.  Low fat/low sugar eating is essential, but it does not have to mean giving up everything one likes.  There is room for ice cream, but trade offs will have to occur.  Exercise can start with walking or whatever one can do – something is better than nothing.  For medication, not every diabetic starts off with insulin.  There are a variety of pills that work, alone or in combination.  They must be tailored to the individual by the health care provider.  Many diabetics, about a third, require insulin.  This is not an admission of defeat.  It acknowledges that the strongest medicine is insulin and it must be used when diet, exercise and pills cannot make the blood sugar normal.  When you boil it down, achieving and maintaining control of the blood sugar greatly reduces the rate of complications of all kinds.  Add to this achieving normal blood pressure and cholesterol levels, and the long-term picture is even better.

HOW DO I KNOW IF I HAVE OR WILL GET DIABETES/CAN I PREVENT IT?  The only way to know is to get your health care provider to check your blood sugar.  If you are thirsty, urinating a lot and have blurry vision, see your doctor tomorrow!  If you want to know your risk, do risk factor assessment.  Risk factors include:

Ø      Age (over 45 years)

Ø      Family history (mother/father/sister/brother with diabetes)

Ø      Having had diabetes when you were pregnant

Ø      Physical inactivity (no regular exercise at all)

Ø      Race/ethnicity (African American / Latino American / Native American / some Asian Americans and Pacific Islanders

Ø      Obesity

Go to the American Diabetes Association web site (www.diabetes.org) and take their diabetes risk test.  This is an excellent source for all kinds of information on diabetes.

Find out from you health care provider if you ever had a sugar in the pre-diabetic range (110-125 fasting; 140-199 non-fasting).  These used to be ignored, but in the last few years we have recognized that they predict people at risk for getting diabetes in the future.  For prevention: diet and exercise prevented the development of diabetes in 40% of people at risk in one study, but you have to keep them up!  A medication also worked, but not as well.

WHAT ELSE? If you don’t have a health care provider and have read this much, it is time to get one.  Ask them if they have a team available for treating diabetes and if they have an organized approach to following patients to guarantee comprehensive care for this at times complex chronic disease.  One doctor cannot provide complete care for diabetes.  It requires educators, nutritionists, nurses and specialists, but there are not enough specialists or specialty sites to care for even half of our diabetics.  One example of a comprehensive diabetes management process based in primary care is the “Staged Diabetes Management” program being instituted at two locations in Springfield, High Street Health Center and Mason Square Neighborhood Health Center.  These sites are bringing their resources together in a coordinated fashion to create more efficient, complete diabetes care for all patients.  The International Diabetes Center in Minnesota is supporting this program with expertise and funding.