Taking Control
A generation ago, diabetes likely would have prevented 5-year-old Madison Hummer from playing sports, spending the day at a friend’s home or even eating her own birthday cake. It might have been expected to end her life before adulthood.
With her blood sugar fluctuating widely, it would have been all too easy for the level to fall precipitously, possibly sending her into a coma, or shoot up, which could also lead to a coma--or death.
But the Manhattan Beach kindergartner and her family have benefited from advances in diabetes testing, monitoring and treatment, including newer and more convenient formulations of insulin, the hormone that governs sugar levels. As a result, Madison swims, plays soccer and has just begun going off to play-dates, albeit with instructions to call home so her mother can determine if her blood sugar needs tweaking. Although her blood sugar must be checked 12 times a day, even in her sleep, her doctors and parents expect her to live a long, happy life.
“Thirty years ago, she would have had a significant decrease in her life expectancy and her ability to have children,” said Dr. Francine Kaufman, head of endocrinology and metabolism at Childrens Hospital Los Angeles. “Now she’s got a pretty good chance of being fine.”
For both children and adults with diabetes, controlling blood sugar is the key to averting complications such as blindness, kidney failure, nerve damage and heart disease. And with that easier to do than ever before, patients are living longer, more active lives.
“I can look at my patients and say, if they have access to health care and care for themselves, diabetes may have some effect on their eyes, but they won’t go blind; it may have an effect on their kidneys, but they won’t have end-stage renal failure,” Kaufman said. They may have some nerve damage, but they’re unlikely to suffer the unrelenting infections that lead to amputation. “Those things are pretty much gone.”
Yet, despite improvements in managing the incurable disorder, the number of patients continues to rise--and 200,000 of them die each year. Further, of the approximately 15 million Americans with diabetes, 6 million are unaware of it.
In Type 1 diabetes, usually found in children like Madison, the pancreas stops releasing the insulin the body needs to be able to burn sugar for energy. Thought to stem from the body’s misguided attack on its own cells, it requires that patients be given the insulin their pancreas stopped making.
In Type 2 diabetes, formerly called adult onset diabetes, the body makes too little insulin and responds poorly to the little it does make. This form accounts for up to 95% of all diabetes and is associated with genetics, obesity and being sedentary. The number of people with it is soaring and, by the time they’re diagnosed, damage has been done.
Doctors are also troubled by a rise in a prediabetic condition called impaired glucose tolerance. Although recent studies showed it can be reversed with diet, weight loss and exercise, unchecked it eventually progresses to Type 2 diabetes.
And, despite all the tools available to keep sugar levels in check, diabetics are still dying in disproportionate numbers from cardiac complications. Heart attacks and strokes kill 75% of all diabetics.
Men with diabetes have not benefited from the reduction in heart disease deaths nearly as much as nondiabetics over the last 30 years, said Dr. Michael Bush, clinical chief of endocrinology at Cedars-Sinai Medical Center in Los Angeles. According to the National Institutes of Health, cardiovascular deaths among diabetic men fell just 13%, compared with a 36% drop among men without the disease.
“And what’s even more striking,” said Bush, “is that whereas nondiabetic women have decreased their risk of heart disease deaths by 27%, in diabetic women, the risk has actually gone up 23% in the last 30 years.”
The successes and limitations leave doctors with a sort of “professional schizophrenia,” noted Bush. Doctors act as cheerleaders to encourage diabetic patients and celebrate when they get the disease under control, while at the same time they view diabetes as “a terrible disease with personal and public health implications.”
“We don’t understand everything about diabetes,” said Bush. But doctors know that “your best chance of a life without serious complications is doing all the things that keep your blood sugar as close to normal as possible--while paying careful attention to blood pressure and cholesterol. The rub is how close and how possible.”
Controlling diabetes isn’t necessarily easy. Diet must be constantly monitored and insulin doses determined by how many carbohydrates are consumed. Patients must watch that their sugar doesn’t drop too low or go too high. In addition, they need to maintain a healthy weight and keep down their blood pressure, cholesterol and triglycerides, all of which require a huge commitment.
The task can be all-consuming.
Madison, for example, is closely monitored, lest her sugar levels drop precipitously, and her mother administers most of the insulin she needs. Away from home, she carries a kit containing finger-pricking pens that school aides use to draw blood for testing. She’s got insulin syringes for an emergency, special glucose preparations and small candies for quick fuel if her sugar dives.
New technology has solved some mysteries of Madison’s condition, including excessive glucose levels upon awakening. Kaufman had her wear a 72-hour continuous glucose monitoring system that recorded readings every five minutes through the period. As a result, Kaufman added a nighttime insulin dose that now keeps her sugar from spiking overnight.
On a recent visit to Kaufman, Madison nonchalantly pricked her own fingertip, touched the blood drop to a testing strip and inserted it into the glucose meter, which registered 132 milligrams per deciliter of blood. That number was on target: Kaufman likes her patients to aim for 70 to 150.
Her mother looks forward to the day Madison switches to an insulin pump, which will eliminate the daily insulin injections. Instead, the small beeper-sized device will deliver insulin through a small catheter inserted into the skin of the stomach. But, for now, says Kaufman: “She’s doing extremely well. ... She’s hit every target we wanted her to hit.”
Here are some of the main areas in which diabetes care and control have moved forward:
Lifestyle Modifications
Doctors increasingly focus on the role of diet and exercise in managing diabetes. Exercise burns excess sugar, keeping it from poisoning body tissues. Madison’s family is big on exercise. (Her dad, sports commentator Craig Hummer, competes in Iron Man-like lifeguard competitions.) For Madison, her mother prefers to rely on activity, rather than extra insulin, when sugar levels get high: “If she’s testing high at 4:30 in the afternoon, I’m not going to give her a shot; we go to the park.” However, finding the right amount of exercise can be tricky: Madison’s sugar reading can plummet from 300 to 40 with just 20 minutes in a pool.
Doctors have also made eating a more flexible proposition.
“In the old days, the concept was: ‘I can never have a piece of cake or candy again,”’ said Kaufman. Today, doctors more often tell patients to go easy on sugary foods and carbohydrates, all the while encouraging calorie restrictions to control weight and advising smaller, more frequent meals to keep sugar levels steadier.
Self-Monitoring
* Finger-stick testing. Up until 1979, when patients began testing their own blood with finger sticks, they relied on notoriously inaccurate urine tests. Today’s electronic blood testing devices constitute “the single most important tool available for our fight against diabetes,” Bush said. “Glucose monitoring data lets you know who the enemy is.”
* The GlucoWatch Biographer. This watchlike device, worn on the wrist or ankle, automatically measures glucose in the clear fluid that sits just beneath the skin’s surface. This device, which doesn’t eliminate the need for finger-pricking, received FDA approval last spring but isn’t expected to be on the market until later this year or early next year. It’s still not as reliable as blood testing and works for only 10 hours at a time.
* Other stickless technology. Researchers are working on more ways to measure glucose, such as arm patches and a device that uses infrared light.
Laboratory Testing and
Other Monitoring
* Continuous glucose monitoring system. This device, worn for three days, measures glucose levels every five minutes. The downloaded data is analyzed by doctors to determine when patient’s sugar levels may be going too low or too high so adjustments can be made.
* Laboratory testing. Doctors used to depend on blood sugar readings to assess how their patients were doing, but those provided only snapshots of glucose levels at particular moments. Today’s gold standard for assessing how well a diabetic is controlling sugar is a laboratory blood test called the glycosylated hemoglobin, or HbA1c, test. When sugar levels rise, they create changes in the hemoglobin, part of the blood that carries oxygen. The test measures a product created when this happens, so the reading gives doctors a sense of how much of the time blood sugar levels have been abnormally high in the previous three months, and thus yields more of a cumulative picture of how a patient has been doing. Diabetics should have a reading of 7% or less, the American Diabetes Assn. advises. “If not, you should rattle the cages a bit ... asking for better care,” said Dr. Tom Buchanan, a diabetes specialist and director of the clinical research center at USC.
Treatment
* Medications. Before 1995, doctors relied on insulin injections or pills containing sulfonylureas, such as Glucotrol, DiBeta and Micronase, which stimulate the pancreas to release more insulin and also reduce how much glucose the liver makes.
Today, there are four newer classes of oral diabetes medications. As a result, Bush said, “diabetes care today means making a recipe to get the additive effects of medicines. It’s like a prizefighter. If you hit ‘em high and hit ‘em low, you’re liable to have much more success.”
Among the choices are the meglitinides, such as Starlix and Prandin, which stimulate the pancreas to release more insulin after eating. There are sensitizers, which make the body respond better to the insulin it can produce. These include glitazones, such as Avandia, taken by about 1.2 million people, and Actos, taken by just under that many, and Rezulin--a $2.1 billion drug withdrawn from the U.S. market in March 2000 after the FDA cited it as the suspect in 391 deaths, including 63 involving liver failure.
There are biguanides like Glucophage, which increase insulin sensitivity and shut off the liver’s production of glucose, and alpha-glucosidase inhibitors, such as Precose and Glyset, which slow the process of breaking down starches and turning them into glucose that then enters the bloodstream.
Doctors are also working to improve the way injectable insulin is absorbed, creating versions of insulin that work at different rates. One, which was genetically engineered to work rapidly, can be taken just before or after a meal and helps avoid very low blood sugar, and excessive blood sugar.
Diabetes product manufacturers made needles shorter and thinner, created insulin pens, a nearly painless alternative to syringes, and even found ways to push insulin into the body without shots. One of those means has been through an insulin pump.
* External insulin pumps. These little machines deliver a steady dose of insulin that’s supplemented at meal times with additional doses based upon the amount of carbohydrates being consumed. The $5,000 pump, usually covered by health insurance, most closely mimics the way the body handles sugars. Yet so far, most patients with Type 1 diabetes and the vast majority of Type II diabetics stick with multiple injections. Bush, for example, said that “no more than a couple dozen” of his 800 diabetes patients use the pump. “I have patients who do extraordinarily well on multiple shots. For them, the pump is a physical commitment they don’t want to make.”
* Implantable insulin pumps. Medtronic MiniMed has developed a hockey puck-shaped pump that a surgeon implants shallowly in the abdomen near the pancreas, where it doesn’t interfere with other organs. Every three months, it’s refilled through a thin membrane in the center of the device. Already approved in Europe, it’s awaiting FDA approval.
* Artificial pancreas. Combining the internal pump with an internal continuous glucose sensor creates an artificial pancreas that measures glucose levels and then releases insulin when it’s needed, eliminating the need for finger sticks. MiniMed’s combination device is being tested in France.
* Inhaled insulin. Several companies are working on insulin powder that can be released into a chamber and inhaled into the lungs, where it’s quickly absorbed. Though still experimental, this would take the place of short-acting insulin.
* Oral insulin. Researchers continue to experiment with insulin that can be absorbed into the tissues of the mouth, as well as insulin that can be swallowed. One company, Emisphere Technologies Inc., recently reported that oral versions of insulin were absorbed through the digestive tract and reduced blood sugar levels.
Transplants
Doctors have very preliminary results with transplanting insulin-producing cells into the body to act like a pancreas. There’s hope that stem cells might one day be programmed to yield functioning bundles of insulin-producing cells.
Meantime, experts express believe that better understanding of the genetic and environmental underpinnings of diabetes will let them intervene earlier in people vulnerable to it.
“What probably will happen in clinical care is we’ll take people who are at risk and put them on diet and exercise and not wait until they get diabetes before we treat them with drugs,” Buchanan predicted.
But with all the progress, what’s still missing, Kaufman said, is a magic bullet for the obesity behind so much Type 2 diabetes.
“We haven’t got a handle on medication that helps people lose weight. The obesity continues and makes the problem often very difficult to manage.”
