Living With Diabetes

Diabetes
"The Silent Killer"

WHEN he was 21 years old, Ken developed a puzzling, unquenchable thirst. He also had to urinate frequently—eventually about every 20 minutes. Soon Ken's limbs began to feel heavy. He was chronically tired, and his vision became blurry.

The turning point came when Ken caught a virus. A visit to the doctor confirmed that Ken had more than the flu—he also had Type 1 diabetes mellitus—diabetes, for short. This chemical disorder disrupts the body's ability to utilize certain nutrients, primarily a blood sugar called glucose. Ken spent six weeks in the hospital before his blood-sugar level stabilized.

That was more than 50 years ago, and treatment has improved considerably during the past half century. Nevertheless, Ken still suffers from diabetes, and he is not alone. It is estimated that worldwide, more than 140 million people have the disorder, and according to the World Health Organization, that number could double by the year 2025. Understandably, experts are concerned about the prevalence of diabetes. "With the numbers we're starting to see," says Dr. Robin S. Goland, codirector of a treatment center in the United States, "this could be the beginning of an epidemic."

Consider these brief reports from around the world.

AUSTRALIA: According to Australia's International Diabetes Institute, "diabetes presents one of the most challenging health problems for the 21st century."

INDIA: At least 30 million people have diabetes. "We hardly had any patients under 40 about 15 years ago," says one doctor. "Today every other person is from this age group."

SINGAPORE: Nearly a third of the population between 30 and 69 years of age have diabetes. Many children—some as young as ten—have been diagnosed.

UNITED STATES: Approximately 16 million people are afflicted, and each year some 800,000 new cases are diagnosed. Millions have the disease but do not yet know it.

Treatment for diabetes is made more difficult because a person can have the disease a long time before it is diagnosed. "Because the early symptoms are relatively mild," notes Asiaweek magazine, "diabetes often goes unrecognized." Hence, diabetes has been dubbed the silent killer.

In view of the prevalence and the severity of this disorder, the following articles will address the questions:

What causes diabetes?
How can those who have the disorder cope with it?

Behind the Name
The term "diabetes mellitus" comes from a Greek word meaning "to siphon" and a Latin word meaning "sweet like honey." These words aptly describe the disorder, for water passes through the person who has diabetes as if it were being siphoned from the mouth through the urinary tract and right out of the body. Furthermore, the urine is sweet with sugar. In fact, prior to the discovery of more efficient techniques, one test for diabetes was to pour a patient's urine near an anthill. If the insects were attracted, this indicated the presence of sugar.

The Challenge
of Treatment

"There's no diabetes that's not bad. It's all serious."—Anne Daly, American Diabetes Association.
"YOUR blood tests came back with significant abnormalities. You need immediate medical attention." The doctor's words hit Deborah like a sledgehammer. "That night, I kept thinking there must have been a lab error," she says. "I told myself I just couldn't be sick."

Like many people, Deborah thought that she was reasonably healthy, so she ignored the nagging symptoms. She blamed her persistent thirst on the antihistamines she was taking. She attributed the frequent urination to an excess intake of water. And the tiredness—well, what working mother does not get exhausted?

But then a blood test confirmed that diabetes was the culprit. It was difficult for Deborah to accept the diagnosis. "I told no one about my illness," she says. "At night, when the family was asleep, I would stare out at the darkness and cry." Upon learning that they have diabetes, some, like Deborah, experience a flood of emotions, including depression and even anger. "I went through a tearful period of denial," says Karen.

These are natural responses to what seems an unfair blow. With support, however, those with diabetes can adapt. "My nurse helped me to accept my condition," says Karen. "She assured me that it was OK to cry. This emotional outlet helped me to adjust."

Why Serious
Diabetes has been called "a disorder of the very engine of life," and for good reason. When the body cannot metabolize glucose, a number of vital mechanisms can break down, sometimes with life-threatening consequences. "People don't die directly from diabetes," says Dr. Harvey Katzeff, "they die from complications. We do a good job of preventing complications, but a poor job of treating [them] once they occur."*

Is there hope for those who are afflicted with diabetes? Yes—if they recognize the seriousness of the disorder and submit to a program of treatment.#

Diet and Exercise
Although Type 1 diabetes cannot be prevented, scientists are studying the genetic risk factors and are trying to find ways to suppress an immune attack. (See the box "The Role of Glucose.") "With type 2, the picture is much brighter," says the book Diabetes—Caring for Your Emotions as Well as Your Health. "Many of those who might be genetically susceptible avoid showing any sign of this disease simply by eating a balanced diet and exercising regularly, thereby staying physically fit and keeping their weight within normal limits."%

Proper diet is essential for diabetes sufferers

Underscoring the value of exercise, the Journal of the American Medical Association reported on a large study involving women. The study found that "a single bout of physical activity increases insulin-mediated glucose uptake [by the body's cells] for more than 24 hours." Hence, the report concludes that "both walking and vigorous activity are associated with substantial reductions in risk of type 2 diabetes in women." The researchers recommend at least 30 minutes of moderate physical activity on most if not all days of the week. This can include something as simple as walking, which, says the American Diabetes Association Complete Guide to Diabetes, "is probably the best, safest, and least expensive form of exercise."

However, exercise by people with diabetes should be professionally supervised. One reason is that diabetes can damage the vascular system and nerves, thus affecting blood circulation and feeling. Hence, a simple scratch on the foot may go unnoticed, get infected, and turn into an ulcer—a serious condition that may lead to amputation if not treated immediately.^

Still, an exercise regimen can help one to manage diabetes. "The more researchers study the benefits of regular exercise," says the ADA Complete Guide, "the better the news gets."

Insulin Therapy
Many with diabetes must supplement their diet and exercise program with daily testing of glucose levels along with multiple insulin injections. As a result of improved health through diet and a good routine of exercise, some with Type 2 diabetes have been able, at least for a time, to discontinue insulin therapy.** Karen, who has Type 1 diabetes, found that exercise increases the efficiency of the insulin she injects. As a result, she has been able to cut her daily insulin requirements by 20 percent.

If insulin is needed, however, there is no reason for the sufferer to feel discouraged. "Going on insulin does not imply failure on your part," says Mary Ann, a registered nurse who cares for a number of diabetes patients. "Whatever form of diabetes you have, if you carefully control your blood sugar, you will minimize other health problems later." In fact, a recent study revealed that people with Type 1 who kept strict control of their blood-sugar levels "had drastic reductions in the occurrence of diabetic eye, kidney, and nerve diseases." The risk of eye disease (retinopathy), for instance, was cut by 76 percent! Those with Type 2 who keep tight control of their blood-sugar levels enjoy similar benefits.

To make insulin therapy easier and less traumatic, syringes and insulin pens—the most common tools used—have microfine needles that give minimal discomfort. "The first shot is usually the worst," says Mary Ann. "After that, most patients say they hardly feel a thing." Other methods of injection include automatic injectors that shoot a needle into the skin painlessly, jet injectors that literally fire insulin through the skin by means of a fine jet blast, and infusers that employ a catheter that stays in place for two or three days. About the size of a pocket pager, the insulin pump has gained popularity in recent years. This programmable device dispenses insulin through a catheter at a steady rate according to the body's daily needs, making insulin administration more precise and convenient.

Keep Learning
All told, there is no blanket therapy for diabetes. When considering treatment, each individual must take into account a number of factors in order to make a personal decision. "Even though you may be under the care of a medical team," says Mary Ann, "you are in the driver's seat." In fact, the journal Diabetes Care states: "Medical treatment of diabetes without systematic self-management education can be regarded as substandard and unethical care."

The more those with diabetes learn about their disease, the better equipped they will be to manage their health and increase their prospects of living a longer, healthier life. Effective education, however, calls for patience. The book Diabetes—Caring for Your Emotions as Well as Your Health explains: "If you try to learn everything at once, you are likely to get confused and not use the information effectively. Besides, much of the most useful information you will need to learn isn't found in books or pamphlets. It has to do with . . . how your blood sugar varies with changes in routine. This can be learned only over time, through trial and error."

For example, by careful monitoring you learn how your body reacts to stress, which can cause your blood-sugar level to shoot up. "I've lived with this diabetic body for 50 years," says Ken, "and I know what it is telling me!" "Listening" to his body has paid off, for Ken is still able to work full-time—even though he is over 70 years of age!

The Importance of Family Support
Not to be overlooked in treatment of diabetes is support from the family. In fact, one reference notes that "the quality of a family's life together is perhaps the largest single factor" in managing diabetes in children and young adults.

It is beneficial when family members learn about diabetes, even taking turns attending medical appointments with the sufferer. Knowledge will help them to be of support, recognize important symptoms, and know how to respond. Ted, whose wife has had Type 1 diabetes since the age of four, says: "I can tell when Barbara's sugar level goes down too low. She will get quiet in the middle of a conversation. She perspires profusely and gets angry for no reason. And her reactions slow down."

Similarly, when Catherine, Ken's wife, observes Ken becoming pale and clammy and when she sees a change in his disposition, she presents him with a simple math problem. Ken's confused response tells Catherine that it is time to take any decision-making out of his hands and act quickly to remedy the situation. Both Ken and Barbara deeply appreciate having informed marriage mates whom they love and fully trust.##

Loving family members should strive to be supportive, kind, and patient—qualities that can help an ill person face life's challenges and can even influence for the better the course of their disease. Karen's husband reassured her of his love, which made a big difference. Karen relates: "Nigel said to me, 'People need to take in food and water to survive, just the same as you need food and water—and a little dose of insulin.' These warm yet practical words were just what I needed."

Family and friends also need to understand that as blood-sugar levels fluctuate, diabetes can affect one's moods. "When I experience sugar-related lows," says one woman, "I get very quiet, moody, easily upset, and frustrated. Then I feel awful about being so childish. But it helps when I know that others understand the reason for these feelings—which I try to control."

Diabetes can be managed successfully, especially if the sufferer has cooperation from friends and family members. Bible principles can also help. How?

* Complications include heart disease, stroke, poor kidney function, peripheral arterial disease, and nerve damage. Poor blood supply to the feet can lead to ulcers, which in severe cases require amputation of the affected limb. Diabetes is also the most frequent cause of blindness among adults.

% Excess fat in the midriff (the apple-shaped body) seems to pose more danger than fat on the hips (the pear-shaped body).

^ Smokers put themselves at an even greater risk, for their habit damages the heart and circulatory system, and it narrows blood vessels. One reference states that 95 percent of diabetes-related amputations involve smokers.

** Some of these people were helped by oral medication. This includes drugs that stimulate the pancreas to release more insulin, others that slow the increase of blood sugar, and still others that lower insulin resistance. (Oral medication is not usually prescribed for Type 1 diabetes.) At present, insulin cannot be taken orally, for digestion breaks this protein down before it reaches the bloodstream. Neither insulin therapy nor oral medication eliminates the need for exercise and a good diet.

## Medical authorities recommend that people with diabetes always carry an identification card and wear identification jewelry. In a crisis these items can save a life. A low-sugar reaction, for example, can be misinterpreted as a different medical condition or even as an alcohol problem.

A Disease
of the Young?

Diabetes is "becoming a disease of the young," says Dr. Arthur Rubenstein, a leading endocrinologist and dean at New York's Mount Sinai School of Medicine. The average age for the onset of diabetes is indeed dropping. "Ten years ago, we were teaching medical students that you didn't see this disease in people under 40," says diabetes expert Dr. Robin S. Goland, speaking of Type 2 diabetes. "Now we're seeing it in people under 10."

Why the increase in diabetes among youths? Sometimes a genetic predisposition is involved. But weight and environment may also play a role. The number of obese children has doubled in the past two decades. What accounts for this? "There have been a number of changes in food habits and activity patterns over the last 20 years," says Dr. William Dietz of the U.S. Centers for Disease Control and Prevention. "These include increased reliance on foods consumed outside the home; increased rates of skipping breakfast; increased consumption of soft drinks and fast foods; reduction of [physical education] in schools; and elimination of recess at school."

Diabetes cannot be reversed. Therefore, it is wise to follow the advice of one teenage sufferer, who simply states: "Stay away from junk food and stay fit."

The Role of Glucose,
the Pancreas, and Sugar

The Role of Glucose
Glucose fuels the body's trillions of cells. To enter the cells, however, it needs a "key"—insulin, a chemical released by the pancreas. With Type 1 diabetes, insulin is simply not available. With Type 2, the body makes insulin but usually not enough.* Moreover, the cells are reluctant to let insulin in—a condition called insulin resistance. With both forms of diabetes, the result is the same: hungry cells and dangerous levels of sugar in the blood.

In Type 1 diabetes, a person's immune system attacks the insulin-producing beta cells in the pancreas. Hence, Type 1 diabetes is an autoimmune disease and is sometimes called immune-mediated diabetes. Factors that can trigger an immune reaction include viruses, toxic chemicals, and certain drugs. Genetic makeup may also be implicated, for Type 1 diabetes often runs in families, and it is most common among Caucasians.

With Type 2 diabetes, the genetic factor is even stronger but with a greater occurrence among non-Caucasians. Australian Aborigines and Native Americans are among the most affected, the latter having the highest rate of Type 2 diabetes in the world. Researchers are studying the relationship between genetics and obesity, as well as the way excess fat seems to promote insulin resistance in genetically susceptible people.# Unlike Type 1, Type 2 diabetes occurs mainly in those who are over 40 years of age.

The Role of the Pancreas
About the size of a banana, the pancreas lies just behind the stomach. According to the book The Unofficial Guide to Living With Diabetes, "the healthy pancreas performs a continuous and exquisite balancing act, managing to sustain smooth, stable blood-sugar levels by releasing just the right amount of insulin as glucose levels wax and wane throughout the day." Beta cells within the pancreas are the source of the hormone insulin.

When beta cells fail to produce enough insulin, glucose builds up in the blood, causing hyperglycemia. The opposite—low blood sugar—is called hypoglycemia. In concert with the pancreas, the liver helps manage blood-sugar levels by storing excess glucose in a form called glycogen. When commanded by the pancreas, the liver converts glycogen back into glucose for use by the body.

The Role of Sugar
It is a common misconception that eating a lot of sugar causes diabetes. Medical evidence shows that getting fat—regardless of sugar intake—increases the risk among genetically susceptible individuals. Still, eating too much sugar is unhealthy, since it provides poor nutrition and contributes to obesity.

Another misconception is that people with diabetes have an abnormal craving for sugar. In reality, though, they have the same desire for sweets as most others. When it is not controlled, diabetes can lead to hunger—but not necessarily for sugar. People with diabetes can eat sweets, but they must factor their sugar intake into their overall diet plan.

Recent studies have shown that a diet high in fructose—sugar derived from fruits and vegetables—can contribute to insulin resistance and even diabetes in animals, regardless of their weight.

* About 90 percent of those with diabetes have Type 2. Previously, this was referred to as "non-insulin dependent" or "adult onset" diabetes. However, these terms are imprecise, for up to 40 percent of those with Type 2 diabetes require insulin. Furthermore, an alarming number of young people—some not even in their teens—are being diagnosed with Type 2 diabetes.

# A person is generally considered to be obese when 20 percent or more above his or her ideal body weight.

Diabetes Simplified
Healthy Person
After a meal, the pancreas (1) responds to increases in the glucose content (6) of the blood, releasing the proper amount of insulin (4).
Insulin molecules (4) become attached to receptors (2) on muscle cells and other cells. This, in turn, activates portals (3) that allow glucose molecules (6) to enter.

Glucose (6) is absorbed and burned by muscle cells. Thus, the glucose level in the bloodstream returns to normal.
Pancreas
Receptor
Portal
Insulin
Nucleus
Glucose
Cell
Red blood cells
Blood Vessel

Type 1 Diabetes
The insulin-producing beta cells in the pancreas (1) are attacked by the immune system. As a result, insulin (4) is not produced.

Without the assistance of insulin (4), the glucose molecules (6) cannot enter into the cells.

Type 2 Diabetes
In most cases the pancreas (1) produces a limited amount of insulin (4).
If receptors (2) are less responsive to insulin (4), portals (3) that are needed to absorb glucose (6) from the blood are not activated.

Glucose (6) builds up in the bloodstream, thwarting vital processes and damaging vessel walls (9).

How the Bible Can Help
Diabetes Sufferers

SELF-CONTROL and a positive outlook are especially vital to the health and well-being of people with diabetes. But to cultivate such qualities, the sufferers need ongoing support. So family members and friends would not want to tempt the person with diabetes to eat unwholesome food, perhaps saying, 'Just this once won't hurt.' "I receive fine support from my wife," says Harry, who has heart disease and Type 2 diabetes. "She doesn't keep foods around that I should not eat. But some others do not understand, and they do not know how hard that makes it at times."

If you regularly associate with a person who has diabetes, keep in mind the following two beautiful precepts found in the Bible: "Let each one keep seeking, not his own advantage, but that of the other person," and "Love . . . does not look for its own interests."—1 Corinthians 10:24; 13:4, 5.

All who are concerned about their health—whether they have diabetes or not—need to exercise restraint with food. The Bible helps in this regard, for it points out the need for each of us to develop self-control. Have you resolved to cultivate this quality in your life? (Galatians 5:22, 23) Additional help can come from Bible examples, such as the Christian apostle Paul. "He had a permanent thorn in his flesh," says one diabetes sufferer, "yet he still served God faithfully and fully. So can I!"

Self-control and a positive outlook are vital

Yes, Paul accepted what he could not change and enjoyed great success as a missionary. (2 Corinthians 12:7-9) Dustin, 18, has been blind from birth, and he has had diabetes since the age of 12. He writes: "I know that no one in this world has everything just perfect. I look forward to the time in God's new world when I won't have diabetes. To me, it is just a temporary thing. It may last longer than a cold or the flu, but eventually it will end."

In making that statement, Dustin had in mind the Bible-based hope of perfect health in a paradise earth under God's Kingdom. (Revelation 21:3, 4) God's Word promises that under such divine rule, "no resident will say: 'I am sick.'" (Isaiah 33:24; Matthew 6:9, 10)