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Taking Control

Advances in managing blood sugar have improved diabetics' lives, but the growing number of patients and complications, including obesity, have doctors concerned.


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.

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