Researchers Struggle to Solve Mystery of Finland’s High Diabetes Rate

For a week’s stay at the birch-shaded lakeside retreat that is this city’s most popular destination, families must wait years and jostle with many times more worthy applicants than the facility can handle.

But what Finns are clamoring for here is not a resort vacation, even if the grounds of the Diabetes Center do evoke the bucolic serenity of a high-end summer camp or spa.

With 3.4% of the Finnish population afflicted with the disease--and with the world’s highest rate, by far, of the insulin-dependent Type 1 diabetes--the mere dozen apartments available to house those who come here to learn how to manage their illness fall tragically short of the massive demand.

Finland’s dubious distinction as the leading diabetes incubator on the planet is one of modern medicine’s more perplexing mysteries, because this country of 5.4 million is among the wealthiest, least polluted and most health-conscious in the developed world.

Diabetes is known to have a strong genetic component, but its causes are many, and leading experts in the research and treatment of the disease continue to scratch their heads when pondering the oft-asked question: Why Finland?

“If I knew that, I would have a Nobel Prize,” said Tero Kangas, a physician who heads the national Research Foundation for Diabetes. “We human beings are chemistry, and very little is known about what happens inside us,” said Kangas, a diabetic for the past 44 years who has written a widely sold manual on coping with the disease.

As scientists in the world’s biotechnology bastions unravel the human genetic code, hopes have surfaced among the 125 million diabetes sufferers around the world--16 million of them in the United States--that the disease’s cause could soon be identified and progress made toward prevention and cure.

“But the job is enormous,” Kangas said. “I’m not pessimistic, but someone would have to be very lucky to find the right gene and the right protein and to draw the right conclusions.”

Jaakko Tuomilehto, who heads the diabetes and genetic epidemiology unit at the National Public Health Institute in Helsinki, the capital, is equally perplexed by the high rate of the disease in Finland. He says he suspects that environmental, viral or behavioral influences may be interacting with the genetic factor.

“The reason why some people with a genetic predisposition get diabetes and others don’t is not very well understood,” Tuomilehto said.

He cites half a dozen intriguing indicators, such as the pronounced higher incidence of diabetes found in the 1960s among the offspring of women hit by the rubella epidemic, and the predisposition for the disease in those born by Caesarean section.

But rubella, or German measles, has been all but eradicated in Finland for three decades through an inoculation program, and the diabetes pattern has only changed for the worse, he notes.

“And Caesarean sections are no more common in Finland than elsewhere, so that doesn’t explain much,” he added.

Researchers in other countries have singled out breast-feeding as an apparent inhibitor of diabetes. But Finland’s generous maternity-leave policy, allowing mothers to stay home with full pay and benefits for nine months, has resulted in broader and longer breast-feeding than in other developed countries--again providing no clue to the nation’s high incidence of both Type 1 diabetes and the more prevalent Type 2, or adult-onset diabetes.

“My own theory is that it is connected to toxic agents in the environment--something that turns on the genes,” Tuomilehto said. “Dietary nitrates and nitrites are commonly used in fertilizing farmland and also in cured meats, which are widely consumed in Finland.”

Tuomilehto also puts caffeine on his list of suspect substances because Finns are among the biggest consumers of coffee in Europe.

Although discoveries about the cause and cure remain elusive, Finland has boosted health spending for treatment and made investment in research a growing priority for the government-run health care network as the national incidence rate climbs every year.

Finland’s unique demographic factors make it a better laboratory for research than the United States and other more heterogenous countries, Tuomilehto says, explaining why the National Institutes for Health in the Washington suburb of Bethesda, Md., decided to conduct case studies here.

Because this country is linguistically and geographically isolated, it is ethnically homogenous, and its prosperity has ensured that most of the population enjoys relatively equal and high living standards. Those factors allow more cost-effective research because there are fewer variables to consider, Tuomilehto says.

He says he suspects that the lack of diversity is linked to Finland’s high incidence of diabetes. “In all genetic diseases, heterogeneity dilutes defects,” Tuomilehto said. “That’s why you shouldn’t marry someone in your own family.”

Of the more than 180,000 Finns with diabetes, about 30,000 are insulin-dependent. But the more numerous cases of Type 2 diabetes and the health complications that tend to come with it are what threaten to inflate the health care budget beyond even prosperous Finland’s resources, Kangas warns.

At the Diabetes Center here, which focuses on training children in self-monitoring and treatment during the summer, weekly groups of 30 diabetics and family members are introduced to the newest methods and equipment. Parents also find some comfort in the company of other families with diabetic children and learn how to negotiate self-help networks in their home communities.

Heikki and Kaisa Pudas’ 10-year-old son, Arttu, was found to have Type 1 diabetes when he was 2. The parents, who now live with their children in Thailand, have had to live with the fear that their two younger sons also might be predisposed to the disease.

“His diabetes was definitely one of the big questions about whether we could cope abroad,” said Heikki Pudas, the managing director of a Finnish engineering firm in Bangkok, who brought the whole family to the Diabetes Center for training in July. “But we’re still under the Finnish health care system and can fly back here in 10 hours if we ever need to--not much longer than it would take to travel from northern Finland. And when we need to contact experts, we can e-mail doctors here.”

The parents watch proudly as Arttu shows off his newly perfected monitoring techniques for a visitor, then injects his insulin dose into his stomach for the first time.

Reflecting Finland’s success in developing wireless communications, a company launched by Finnish cellular phone giant Nokia and Silicon Valley’s e-health innovator ENACT offers continuous feedback between a patient’s cellular-connected monitoring device and an Internet database. The firm, LifeChart of Mountain View, Calif., has been available to diabetics in Finland since last fall and expects to launch U.S. service soon.

“There have been such huge developments in medical supplies and equipment that it’s much easier for people to monitor and treat themselves,” said Leena Etu-Seppala, head of the Finnish Diabetes Assn.’s prevention and care program. “Devices like the insulin pen are now so small and look so natural--that helps a lot.”

Most of those accepted for training at the center here are Type 1 diabetics; the priority always has been to help those with the type perceived as more threatening because it is fatal if untreated.

But researchers have appealed for more investment and consideration for the Type 2 cases because they are the real economic time bomb.

Kangas estimates that health care costs for diabetics will increase 60% over the next few years, consuming an ever-larger share of the national budget.

“This is the only way to get the attention needed on Type 2 diabetes,” he said. “It has now become too expensive to ignore.”

Williams was recently on assignment in Finland.