'It's scary and a big change'

Learning to live with the disease


For 58-year-old Joyce Tobias, that's what it was like to find out she had type 2 diabetes. The Latrobe woman was diagnosed in April when blood tests, initially performed as part of a routine annual physical, confirmed that her glucose levels were too high.

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"At first, I didn't really believe them," she said. "I had none of the symptoms ... and it doesn't run in my family on either side."

Mrs. Tobias wasn't drinking or urinating more frequently, wasn't hungrier, wasn't experiencing blurry vision or fatigue. A closer look at the health of the family tree revealed only that two uncles had "borderline" sugar problems.

For a few days before the tests were repeated, she cut back on sweets and carbohydrates, hoping that would make the numbers look better. But the tests showed her blood sugar still ran high, and likely had for a while.

And that meant Mrs. Tobias was one of the 1.5 million people diagnosed with diabetes each year in the United States. Most have type 2; about 10 percent have type 1.

Her biggest fear was that she couldn't control her glucose levels. "If it's too low, you can pass out," Mrs. Tobias said. "And if it's always too high, it affects your feet and kidneys and all those other things."

At a diabetes education class in early July, she found out the hard way that she can't judge her blood sugar solely by how she feels.

Mrs. Tobias was being taught to prick her finger and check her glucose levels with a monitor, which she now does at home three to four times daily.

What else to watch for
Here's a list of things Dr. R. Harsha Rao, an endocrinologist, recommends his type 2 patients do in addition to watching their A1C levels:
  • Take a daily aspirin to reduce the risk of cardiovascular complications
  • Get LDL, or "bad," cholesterol under 100.
  • Maintain blood pressure at or less than 130/80.
  • Have an annual eye exam by an optometrist or ophthalmologist.
  • Have an annual foot exam to screen for loss of sensation.

The first time she did it, her sugar came back a too-low 63. Her instructor gave her a half-cup of pop to drink and retested 15 minutes later. Her sugar had gone up to a safer 96. Do you feel better? the instructor asked.

"Well, I didn't feel any different," Mrs. Tobias recalled. "I didn't know it could go that low. I ate breakfast, but I only had a cucumber for lunch."

She now realizes that she'll have to eat regularly to keep her blood sugar balanced with the drugs she takes for diabetes.

Mrs. Tobias is also learning to modify her diet to limit carbohydrates, and is trying to be more active. She belonged to a health club for several years and used to go for half-hour walks until heel pain stopped her.

Exercise along with diet changes helped her drop more than 20 pounds. She said she's still about 50 pounds too heavy.

In addition to seeing the diabetes educator again, Mrs. Tobias will be making appointments to follow up with her doctor and to get her eyes examined. She'll log her testing results and keep an eye on how many grams of carbs she consumes.

The prospect of living with type 2 diabetes often seems overwhelming to her.

"There's a lot to learn," Mrs. Tobias noted. "It's scary and it's a big change."

When to get tested

According to American Diabetes Association guidelines, everyone 45 or older, especially those who are also overweight, should consider getting screened for type 2 diabetes every three years.

Those younger than 45 and carrying excess pounds but have another risk factor, should consider getting tested, too.

Risk factors
You may want to talk to your health care provider about your risk for pre-diabetes if you have any of the following, a list provided by the National Diabetes Education Program:
  • Age: risk increases with age (especially 45 years and older)
  • Overweight: Body Mass Index (BMI) 25 or higher (23 or higher if Asian American, 26 or higher if Pacific Islander) Ask your provider to calculate it for you.
  • Family history of diabetes: having a parent, brother, or sister with diabetes.
  • Race/ethnicity: African American, American Indian, Alaska Native, Asian American, Pacific Islander or Hispanic American/Latino heritage.
  • History of gestational diabetes: also giving birth to a baby weighing more than 9 pounds.
  • Blood pressure: 140/90 or higher.
  • Cholesterol: HDL cholesterol less than 40 for men and less than 50 for women; triglyceride level 250 or higher.
  • Inactive lifestyle: exercises fewer than three times a week.

People are at greater risk for type 2 diabetes if they have a parent or sibling with the condition; are African American, American Indian, Asian American, Pacific Islander, or Hispanic American/Latino; had gestational diabetes, meaning diabetes during pregnancy; gave birth to at least one baby weighing more than 9 pounds; have high blood pressure; have abnormal cholesterol levels; or exercise less frequently than three times a week.

Statistics from the state Department of Health indicate that more than 60 percent of Pennsylvanians age 30 and older are overweight or obese, which means a sizable number of the population should be regularly tested for type 2 diabetes. Physicians typically order a fasting blood glucose test -- no food or drink eight hours beforehand -- to check for diabetes, with cholesterol measured at the same time, as part of the routine physical. Or they might check a random, nonfasting level first and, if it's high, follow up with a fasting sample.

A fasting sugar reading of up to 100 milligrams per deciliter is considered normal. If the result is between 100 and 125, the patient may be heading toward developing full-blown diabetes.

"Even if you don't have diabetes, you can have pre-diabetes or glucose intolerance," said Dr. Wayne Evron, medical director of the Joslin Diabetes Center affiliate at Western Pennsylvania Hospital. "If you catch it then, you might prevent it from progressing. That's why it's so important."

If the level is 126 or higher, then the fasting sugar test may be repeated to confirm the diagnosis of diabetes. If it's higher than 200 and symptoms such as frequent urination are present, then the blood test need not be performed again to make the diagnosis.

Some people with high blood sugar readings also have the other components of a cluster of abnormalities known as metabolic syndrome: high levels of body mass, blood pressure, triglycerides and LDL, or "bad" cholesterol; and low levels of HDL, or "good" cholesterol.

In addition to an increased risk for developing type 2 diabetes, people with metabolic syndrome have a higher risk for coronary artery disease, stroke and peripheral vascular disease.

Not so long ago, it wasn't unusual for doctors to tell patients newly diagnosed with type 2 diabetes to try dietary changes and to increase physical activity -- with the aim of reducing weight and blood sugar -- for several months before reassessing the situation.

These days, depending on glucose levels, initial treatment is likely to include medication as well as lifestyle changes, Dr. Evron said.

"You have to pick certain goals and be very aggressive with them," he said.

Separate causes

Both type 1 and type 2 diabetes result in elevated blood sugar, but their causes are quite different. In type 1, once called juvenile-onset or insulin-dependent diabetes, the beta cells of the pancreas stop making insulin, a hormone that is needed for glucose, or sugar, to be taken into body cells, where it is used for energy. The condition is thought to be auto-immune in nature, meaning the body mistakenly destroys its own healthy cells.

In type 2, formerly called adult-onset diabetes, the beta cells are able to make sufficient amounts of insulin for a while. But the body's cells, particularly fat, liver and muscle cells, become insensitive to the hormone's presence, and so don't open the door for glucose entry. Experts call this phenomenon "insulin resistance."

The body overcomes this problem by making more insulin, said endocrinologist Dr. R. Harsha Rao, who splits his time between the University of Pittsburgh and the VA Pittsburgh Healthcare System. Some people may be able to make so much extra insulin that their blood sugars never become abnormal, and they are never diagnosed with type 2 diabetes.

Many others, though, have beta cells that eventually fail to meet an increasing demand for the sugar-regulating hormone.

"The longer you have insulin resistance, the more likely you are to develop the beta cell defect over time," Dr. Rao said. He added that scientists have not proven insulin resistance is the cause of the defect, although it's a popular theory. Some contend that they are two distinct, albeit concurrent, problems.

Both factors must be considered when treating type 2 diabetes.

Diabetologists began adding medication to diet and exercise modification as initial treatment because of findings from the landmark United Kingdom Prospective Diabetes Study, announced nearly a decade ago, Dr. Rao said.

For 20 years, researchers at 23 U.K. sites tracked more than 5,000 type 2 diabetes patients randomly assigned to meet either the conventional blood glucose levels of the time or more strict measures using nutrition management, the drug metformin, or insulin.

After 10 years, 95 percent of the participants in the intensive management arm could not keep their blood sugars at about 110 through diet strategies alone, even though they had three to four visits annually with a nutrition expert, he said.

"With most insurance plans, you're lucky if you get one nutrition visit paid for, let alone three or four per year," Dr. Rao noted. "So you come up against the reality that it doesn't work and it isn't available even if it did work."

He emphasized that diet and lifestyle modification have been proven to have a profound, beneficial impact for patients with pre-diabetes. And, he added, while good nutrition is not an effective, sole strategy for the long-term control of type 2 diabetes, poor nutrition can clearly make matters much worse.

Medications can help

Several oral medications are used for type 2 diabetes treatment. The workhorse is metformin, which increases sensitivity to insulin and reduces the liver's production of glucose. Some drugs, such as glyburide, stimulate pancreatic beta cells to make insulin.

Other medications interfere with the breakdown of starches and some sugars to slow the rise of blood glucose levels after a meal. Avandia, a newer and popular diabetes drug, has been mired in controversy because of concerns about cardiovascular side effects in a patient population that is already at very high risk for heart attack.

Combinations of the oral agents may be prescribed if a single drug is ineffective.

Eventually, though, the beta cells may not be able to produce enough insulin to get the body to respond. Then, like those with type 1 diabetes, type 2 patients have to regularly inject themselves with it.

Some patients already have glucose levels soaring over 300 when they are diagnosed and must be treated with insulin because it's the only intervention that will work, Dr. Rao said. That also gives the pancreas a break from pumping out vast amounts of the hormone.

The U.K. study showed that despite keeping blood sugars well in control, beta cells eventually failed and more medication, including insulin, had to be added. Some patients didn't need it for decades, while others required it after a few years.

Still, many doctors "are afraid to use insulin," West Penn's Dr. Evron said. "Some people should start much earlier than they do. They allow sugars to be high for way too long."

And that opens the door to the development of serious complications, such as eye, kidney and nerve damage, he said.

Use glucose meter

Experts recommend that all diabetes patients, especially those who are taking medication, are pregnant, or are prone to extreme drops or rises in blood sugar, regularly check their levels with a glucose meter.

"It never hurts [and] it's so easy," Dr. Evron said. He added that keeping tabs on glucose levels can provide valuable feedback that motivates people with pre-diabetes to fend off the progression to diabetes.

To do a check, a drop of blood is placed on a test strip that is inserted into a special meter that quickly gives a glucose reading.

Blood sugar below 180 is acceptable if the test is done just after a meal. The reading should be between 90 and 130 if the test is performed before a meal.

Sometimes, as in Mrs. Tobias' case, people don't eat enough or exercise too much for a given dose of medicine and develop hypoglycemia, meaning their blood sugar drops too low. Symptoms include shaking and dizziness, sweating, hunger, tingling around the mouth, clumsiness, confusion and behavior changes.

The brain needs sugar to work properly, Dr. Evron said. "It cannot use fats, cannot use any other fuel. If the brain does not have enough sugar, it goes into coma."

Mild hypoglycemia can be corrected quickly with some juice or pop or other sugary treat.

Hyperglycemia, or elevated blood sugar, isn't as immediately threatening unless the level is above 500 or so, Dr. Rao said. Symptoms such as frequent urination may occur after long periods above 200, but for the most part, patients don't realize that there is a problem.

"They go puttering along with a blood sugar at 200 or 300 and they ignore it," he said. "That's the insidious nature of this disease."

High sugars set the stage for the development of complications. So to get an idea of what glucose levels have been like over a long period, diabetes patients have an A1C blood test every few months to measure how much glucose has attached to hemoglobin molecules in red blood cells to reflect how sugary the environment has been.

A normal A1C value is around 5 percent, which means the average daily fasting glucose has been about 90.

Dr. Rao cannot emphasize it enough: "Every diabetic must know their A1C like they know their age, their weight and their cholesterol," he said.

The American Diabetes Association recommends that type 2 patients aim for an A1C of less than 7 percent. The British study found that participants who maintained that level were less likely to develop kidney, eye and nerve complications than those who had an A1C of 8, Dr. Rao said.

"Unfortunately, it was not shown in [the British study] an equally significant impact on the thing that kills you, which is a heart attack," he noted. From a mortality perspective, he added, "we don't know that 7 is better than 8."

Dr. Rao and investigators at VA Hospitals nationally have been conducting since 2001 a trial to determine whether an A1C of 6 is better able to stave off heart attacks and strokes among type 2 diabetes patients.

Common sense might suggest an A1C that is closer to normal would be better, but the British study found that tightly controlled type 2 diabetes patients had two to three episodes annually of hypoglycemia so severe that they couldn't help themselves and needed treatment in the emergency room.

In other words, "the closer I get you to the edge of the cliff, the more likely you are to fall off when you stumble," Dr. Rao said. "So do I want the patient who has got a poor sense of equilibrium really close to the edge of the cliff? The answer is no."

Some patients are better off with an A1C of 7.5 or 8 because of their risk for life-threatening hypoglycemia, he said. Others may not have problems even with an A1C closer to 6.

"The more tightly controlled you are, the more frequent followup you need [and] the more poorly controlled you are, the more frequent followup you need," Dr. Rao said. Translation: "Please see a doctor."

Anita Srikameswaran can be reached at anitas@post-gazette.com or 412-263-3858. First Published August 26, 2007 2:30 AM


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