Sixty out of every one thousand Americans reading this article have a disease that will, on average, shorten their lives by about twenty years. Twenty of these sixty people are not even aware that they are ill. That disease in question is diabetes and the likelihood of acquiring it is increasing. The Centers for Disease Control in Atlanta, Georgia, project that current dietary and lifestyle trends should lead to an increased prevalence of the disease over the next twenty-five years. However, with the proper treatment and lifestyle changes, many of the possible complications of this disease, such as blindness, amputations, heart problems, kidney failure, and premature death, can be prevented or delayed.

Diabetes is a chronic disease that impairs the body's ability to use food properly. Normally, glucose, a form of sugar produced when starches and sugars are digested, is burned as fuel to supply the body with energy. This process of turning food into energy is called metabolism. Everyone has glucose in their blood, whether or not they have diabetes. This glucose comes from food. When we eat, the digestive process breaks down carbohydrates into glucose, which is absorbed into the blood in the small intestine. But in order to metabolize glucose properly, the body requires a substance called insulin. The pancreas, a gland located just beneath the stomach, produces the insulin necessary to regulate the body's use of glucose.

Insulin is essential to the metabolic process. Trying to burn glucose without insulin is like trying to set fire to a pile of logs without a match. It can't be done. And that's the problem with people who have diabetes. They either don't produce enough insulin to properly metabolize glucose or the insulin they have works inefficiently. Without insulin to turn glucose into energy the glucose piles up in the bloodstream and spills into the urine showing as sugar in the urine. Excessively high levels of sugar in the blood and the urine are the hallmarks of untreated diabetes.

While there is no cure for diabetes as of yet, it can be controlled. The main goal of diabetes treatment is to control blood sugar levels and keep them in the normal range. The specific kind of treatment used to control blood sugars depends on the type of diabetes a person has. There are four identified types of diabetes with different causes, complications and therapies. The most severe form of diabetes is Type I. In this form of diabetes, a person's pancreas produces little or no insulin. Although the causes of this are not entirely known, scientists believe that the body's own defense system (the immune system) attacks and destroys the insulin-producing cells in the pancreas. Because insulin is necessary for life, people with Type I diabetes must take one or more injections of insulin every day in order to metabolize their food.

The early symptoms of Type I diabetes are: frequent urination in large quantities, excessive thirst, extreme hunger all the time, sudden weight loss for no apparent reason, weakness, drowsiness or exhaustion, sudden vision changes or blurred vision, nausea and vomiting. Before the discovery of insulin in 1921, people with Type I diabetes would fall into a diabetic coma and die, usually within a few weeks of onset. This form of diabetes used to be known as juvenile diabetes because it usually starts in children or young adults.
The most common form of diabetes is Type II. In this form of diabetes, the pancreas still produces insulin, but for some reason the body is not able to use it effectively. So, in spite of the presence of adequate amounts of insulin, blood glucose levels remain abnormal.
Fortunately, Type II diabetes can be treated in a variety of ways, including weight loss, proper diet, reduced sugar intake and exercise. More severe cases may be treated with oral drugs or insulin injections. Type II, which is also known as adult-onset diabetes, occurs most often in people over 40, many of which are over weight.

The symptoms of Type II diabetes are similar to those associated with Type I, but they usually occur more gradually. In addition to those symptoms, Type II sufferers may experience recurring or hard-to-heal skin, gum or urinary tract infections, drowsiness, tingling or numbness in hands or feet, and itching of the skin and genitals.
A rarer form of the disease is called Gestational Diabetes. This type can suddenly appear in pregnant women who have never exhibited any signs of high blood glucose. The hormonal changes of pregnancy stress the mother's system and, in some cases, the pancreas is unable to produce sufficient insulin. Treatment for gestational diabetes ranges from diet management to insulin therapy. While this type of diabetes usually disappears after the birth of the baby (with a birth weight over 9 pounds), 30 to 40 percent of these women develop diabetes within 5 to 10 years.

The most subtle and mild form of the disease is known as Glucose Intolerance. This condition used to be called latent or borderline diabetes, but it is no longer considered a form of diabetes. People with glucose intolerance have an abnormal response when large amounts of carbohydrates are consumed. They are unable to metabolize it normally. Such people are at increased risk for developing diabetes, but most do not.

Out of about eight million people diagnosed with diabetes, one million are Type I and seven million are Type II. Another eight million people are Type II but have not yet been diagnosed. The root cause(s) of either type of diabetes remain unidentified but doctors do understand the tendencies that put one at risk. Diabetes is not strictly genetic. Most children of diabetic parents do not develop the disease. However, a family history of the disease appears to increase the risk. Scientists have long suspected that heredity plays a role since Type I diabetes tends to run in families. While researchers have found several genes that appear to increase the risk of developing Type I diabetes. they haven't identified a single gene that actually causes the disease.

Type I diabetes also shares many of the hallmarks of an auto-immune condition. In auto-immune diseases, the immune system, which protects you from disease by killing invading germs, mistakes the body's own cells for germs and destroys them. In the case of Type I diabetes, the immune system kills the cells in the pancreas that produce insulin. Type I diabetes can often strike shortly after a viral infection, and doctors often notice a sharp jump in Type I diabetes diagnoses after viral epidemics. The most common viruses associated with diabetes include those that cause mumps, German measles, and a close relative of the virus that causes polio. Doctors do not believe that the viruses cause diabetes directly. Instead, these viruses contain proteins that look very similar to proteins found in the pancreas' insulin-producing beta cells. The immune system presumably mistakes the beta cells for virus particles and destroys them, along with that person's ability to synthesize insulin.
Studies have also shown that Pyriminil, a poison used to kill rats, can trigger Type I diabetes along with two prescription drugs: Pentamidine, used to treat pneumonia, and L-asparaginase, a cancer treatment. Other chemicals have been shown to cause diabetes in animals, but scientists are unable to tell if they would do the same in humans because it is medically unethical to test them in people. All the chemicals and drugs that cause Type I diabetes do so by destroying insulin.

Some studies suggest that exposure to cow's milk during infancy may increase the risk of Type I diabetes. Cow's milk contains a protein similar to a protein found on beta cells. The theory is that: If infants develop antibodies to the cow's milk protein, the antibodies may mistake the beta cells for milk and destroy them. The cow's-milk connection has always been controversial, and it recently became more so when a well designed study by University of Colorado researchers showed no link between cow's milk exposure in infancy and increased risk of Type I diabetes. However, even a remote chance that cow's milk might increase risk of diabetes strengthens the case for breast-feeding.

The risks associated with Type II diabetes include several lifestyle and dietary factors. Most people with Type II diabetes have sedentary lifestyles, and are obese, usually weighing at least 20 percent more than what's recommended for their height and build. Type II disease also runs in families, which suggests some genetic component. In fact, a genetic link seems even stronger in Type II diabetes than in Type I. Scientists have not yet identified a single gene that causes the disease, but they are finding errors in several genes that may contribute to the disease. Researchers also suspect a genetic susceptibility to obesity is related to the incidence of diabetes.

Obesity is the single most important cause of Type II diabetes. Definitions of obesity differ, but in general, you're obese if you weigh at least 20 percent more than what's recommended for your height and build. Three-quarters of Type II diabetics are or have been overweight. For reasons that remain unclear, carrying excess body fat somehow causes insulin resistance. That's why Type II diabetes is usually treated with diet and exercise. Dropping weight and gaining muscle helps the body use insulin more efficiently. JoAnn Manson, MD.., an epidemiologist and endocrinologist at Harvard Medical School has found that in a dozen studies which followed tens of thousands of people for many years, being overweight increased the risk of diabetes more than tenfold. We monitored the health of 87,000 female nurses, and found that most of the new diabetes diagnoses could be attributed to extra weight. However, diabetes is not just a matter of carrying a few extra pounds. It also matters where you carry those pounds. Being heavy around the belly (apple shaped) appears to be worse than being heavy in the thighs (pear shaped).

Age also plays a role in Type II diabetes. Half of all new diagnoses are people over 55, and nearly 11 percent of Americans aged 65 to 74 have type II diabetes. However, it's not clear whether age, per se, is a cause of Type II diabetes, or simply a reflection of the fact that people tend to gain weight and become less physically active as they grow older.
The three critical elements for controlling diabetes are food, exercise and insulin. The rule of thumb is that food makes the glucose level rise and exercise and insulin make the glucose level fall. Diabetes control is a constant balancing act of these three factors. If the balance is lost, one of two diabetic emergencies is likely: Hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). Hyperglycemia is much less frequent than hypoglycemia. Hypoglycemia, sometimes called insulin shock, occurs suddenly, if a person using insulin eats too little food, doesn't eat soon enough, takes too much insulin, or exercises too much. This condition must be treated quickly with sugar or sugary foods because hypoglycemia can lead to unconsciousness. If a person becomes unconscious, honey or syrup should be rubbed inside the person's cheek, where it can be absorbed without risk of choking. If the person does not respond within 10 to 15 minutes, Glucagon, a hormone that raises blood sugar, may need to be injected.

Symptoms appear rapidly but each individual has a personal set of symptoms which are unique to them. Care must be taken to identify those symptoms. Some patients show no preliminary symptoms at all and therefore need to monitor their blood sugar levels more frequently. The most common notable signs of Hypoglycemia include: inappropriate responses, crankiness, confusion and inattention, lack of coordination, drowsiness, pale complexion, perspiration, headache, trembling, sudden hunger and dizziness.

If a diabetic falls into a state of hyperglycemia and the condition isn't treated immediately, a dangerous biological process occurs. Since the body can't use the sugar to supply its energy needs, it starts to steal energy from the fats stored in the body. When fats are broken down, acids called ketones are formed in the body. Too many ketones in the system become poisonous. Without proper treatment, the diabetic may fall into a coma requiring hospitalization. This condition can be fatal. Fortunately, it develops graduallyÑover several hours or days. Prompt attention to the warning signs can help avert a serious problem. Usually a diabetic coma occurs only in Type I diabetes. Symptoms occur gradually and may include: extreme thirst, drowsiness, lethargy, sugar in urine, dry hot skin, lack of appetite, high levels of sugar in the blood, fruity, sweet or wine-like odor on breath, heavy, labored breathing and eventual stupor or unconsciousness.

These problems can be easily avoided by properly monitoring blood sugar levels. Indeed, one of the most important advances in diabetes treatment and control has been the ability to measure and monitor blood sugar levels at home. Whether insulin-dependent or non-insulin-dependent, people with diabetes must understand how the disease works and learn how to manage their blood sugar levels. They should test their blood at specified times of the day in order to maintain a healthy glucose to insulin balance. Diabetics must also take very good care of themselves, paying attention to diet, eating habits and exercise. Blood sugar levels can be measured at home with a blood glucose monitoring system. It involves placing a drop of blood on a chemically treated strip, which is then put into a meter for a blood sugar reading. Another method relies on a visual comparison of the strip with a color-coded chart. It is believed that with more precise monitoring and better control, the complications of diabetes can be reduced, even reversed.

Type I diabetic patients must take insulin injections every day to make up for the hormone their bodies do not produce. An insulin injection is only a rough estimate of what is really needed. If you take one shot in the morning, and then suddenly decide to do some vigorous exercise without taking into account the extra sugar that will be burned, the body may be left with too little sugar and too much insulin. This may lead to hypoglycemia as described above. Any person with Type I diabetes learns that before engaging in strenuous activity, they must either consume extra carbohydrates to compensate for the sugar that will be burned, or take less insulin that day. This regimen should be discussed with one's personal physician. Other factors which can upset the balance include: physical activity, illness, infection, periods of growth, fatigue, excitement, anxiety, and hormonal changes.

Most cases of Type II diabetes can be controlled by diet and exercise alone. The specific diet and exercise plan a doctor or dietitian recommends will depend on a person's age, lifestyle and overall physical condition. In some cases, oral drugs or insulin injections may be necessary as well. The key is to controlling Type II diabetes is to determine the right balance of these elements.

Check with your physician before starting an exercise program to determine what activities will be best for you. Exercise is important both because it helps to control weight and because it burns food, reducing demand on the pancreas to produce insulin. Weight loss through diet is a must for the overweight person with diabetes. Often, once the desired weight is maintained, no other treatment is necessary. A personal meal plan should aim for a fixed number of calories each day. Cholesterol and saturated fats should be restricted because people with diabetes are at a higher risk of heart attack.

Maintain a regular pattern of eating, exercising, and resting. Changes of schedule require adapting the diet or insulin dosages appropriately. For instance, if you have Type II diabetes and are going to a very late dinner, you should work in a little snack at your normal dinner hour. Concentrated sugars should be avoided since the body cannot produce insulin fast enough to burn them.

Over time, diabetes can cause complications in organs and systems throughout the body. It affects the blood vessels and the heart, increasing the risk of heart disease, stroke, and other problems caused by poor circulation, such as gangrene. Diabetes is the leading cause of adult onset blindness in North America. Damage to the blood vessels in the retina is evident in 90 percent of all persons who have had diabetes for 15 years or longer. Kidney disease is also a major complication resulting from diabetes. About 30 percent of new dialysis patients have diabetes induced kidney failure. In addition, the incidence of stroke is two to six times higher in people with diabetes. Simply put, diabetes is a chronic, complicated and destructive disease.

However, there is increasing hope that diabetes and its related problems can be cured. Researchers are beginning to understand how the body's own immune system destroys insulin-producing cells. Others are attempting to identify the genes involved in diabetes to define those at risk. Research and development is currently investigating insulin pumps and other experimental insulin-delivery systems along with new ways to monitor blood glucose. Pancreas transplants are perhaps the most effective method of treatment currently in use. This procedure continues to be the only available procedure that, when successful, keeps blood sugar levels balanced and eliminates the need for insulin injections altogether, markedly improving the quality of life for the patient. The simpler and less-invasive transplant of insulin producing pancreatic cells (islet cell) is done less frequently in diabetic patients and is still considered experimental. The downside for patients who have had a successful transplant is the lifelong need to take potentially harmful immunosuppressive drugs. However, recent advancements have improved the odds for whole-organ recipients, while islet research is producing promising initial results as well.

The benefits of finding a cure or even producing more effective treatments for diabetes would be enormous. The total annual economic cost of diabetes in 1997 was estimated to be $98 billion dollars. That includes $44.1 billion in direct medical and treatment costs and $54 billion for indirect costs attributed to disability and mortality. In 1997, the per capita costs of health care for people with diabetes amounted to $10,071 while health care costs for people without diabetes amounted to $2,699.

Juvenile Diabetes Foundation 120 Wall Street New York, NY 10005-4001 1-800-JDF-CURE

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