It is one scary word to hear tumble off a doctor's tongue:

Diabetes.

Lake Fong, Post-Gazette Linda Torch, 54, was diagnosed with type 2 diabetes in 2003. She has since lost 50 pounds by walking and counting carbohydrates in her diet. Click photo for larger image. Related coverage Video: Linda Torch learns to live with type 2 diabetes In hypothetical village, 90 people have diabetes and the ills that come with it Q&A: A quick look at type 2 diabetes Graphics Diabetes on the rise, U.S., 1980 to 2005 Diabetes in Pennsylvania, 1995 to 2006 Pennsylvania diabetes death rates by race U.S. obesity trends, 1985-2006 Pennsylvanians who are overweight and obese

When Linda Torch was diagnosed with type 2 diabetes in 2003, it meant she had fallen victim to an epidemic sweeping the nation -- and her family.

Her father died at age 72 of the disease and her husband at 45. Her brother, at 68, became its latest victim, in April, and her mother and three remaining siblings also have the disease. She knew that doing nothing to control her blood sugar would be a fatal error.

"Everything's against me," said Mrs. Torch, 54. "But I still keep going."

About 20.8 million Americans have diabetes, including 6.2 million still undiagnosed, according to the Centers for Disease Control and Prevention and American Diabetes Association.

Linda S. Geiss, chief of diabetes surveillance at the Centers for Disease Control and Prevention, said the scope of the problem is even bigger once the 54 million Americans at risk of diabetes because of elevated blood-sugar levels are included.

Altogether, that means that at least one quarter of the American population either has diabetes or is at risk of getting it.

"We're on a fast moving train -- a speeding train that since the '90s has taken a pitch upward," said Dr. Ann Albright director of CDC's Division of Diabetes Translation. "We have to slow it down before we can turn it around."

Diabetes killed 224,000 people in 2002, making it the nation's sixth- leading killer. But the ADA says the actual number is much higher because diabetes complications, including heart disease and stroke, typically are listed as the cause of death instead of the disease itself.

According to the CDC, one in three of all Americans born in 2000 and one of every two African Americans, American Indians, Hispanics and Asians will develop diabetes in his or her lifetime.

Diabetes especially victimizes people of low income who are least able to afford treatment and to control their disease. Another concern is that type 2, formerly described as adult-onset diabetes, is showing up in school-age children, a Pittsburgh Regional Healthcare Initiative report says.

Diabetes occurs when the body fails to produce or properly use insulin, the hormone needed to convert sugar, starches and other food into energy. Although the cause is a mystery, genetics and environmental factors such as obesity and lack of exercise all appear to play a role in developing type 2, the ADA says.

Type 2, which usually occurs in working-age adults, is preventable in many at-risk people with dietary changes, weight loss and exercise. Treatment for type 2 usually involve oral medications, but also can include insulin injections like those used by people with type 1, or juvenile, diabetes.

Five to 10 percent of all people with diabetes -- fewer than 2 million Americans -- have type 1, which most often occurs in children and young adults. The chronic disease, with no known cure, occurs when an autoimmune disorder destroys the beta cells that produce insulin in the pancreas. Insulin injections reduce blood-sugar levels.

But high blood-sugar levels have the same health consequences for both types. Key to control is reducing high blood-sugar levels to the normal range, or as close to normal as possible, to reduce or prevent health complications.

A third type of diabetes -- gestational -- can affect pregnant women and increase their and their children's risk of developing type 2.

Difficult to stop it

The diabetes epidemic may be worse in Pennsylvania than elsewhere, in part because a large share of Pennsylvanians are elderly, a risk factor for the disease.

Replying to a national survey in 2006, 7.5 percent of adult respondents nationwide said they had been told by a health care professional that they had diabetes. In Pennsylvania, the percentage was 8.5 percent in 2005, but climbed to 9 percent in the most recent survey in 2006, with some rural counties at 10 percent.

As the problem grows, the health care system is struggling to provide optimum care and to help people manage the disease. Exactly what will stem the tide is unclear, though experts believe that health-promotion efforts or revamping the health care payment system might help.

"It's worse every year, and that's why it is so frustrating to me," said U.S. Rep. John Murtha, D-Johnstown, who has sponsored government initiatives to control diabetes in Pittsburgh, rural Western Pennsylvania and in the military. "How can we have an impact?"

Controlling blood-sugar levels determines whether one can live a normal life or suffer progressive decline from complications including heart disease, stroke, renal failure, blindness, gum disease, thyroid disorders, nerve damage and circulation problems that can lead to lower-limb amputations.

But tight control requires work, including a strict regimen of medications, blood glucose testing, dietary changes and exercise. Overlooking any of the four can cause blood-glucose levels to go awry. That is why diabetes experts emphasize prevention through diet, exercise and weight loss.

Mr. Murtha questioned whether it would work to scare people into better control or offer financial rewards or rebates to those who bring test results into acceptable levels. Perhaps marketing campaigns could help persuade Americans to eat better and exercise more often, he said.

He pointed out that 57 percent of enlisted military personnel are overweight, and diabetes is prevalent among them, their families and retirees, at great cost to the nation. If the military cannot keep people fit, he said, what are the chances of controlling the epidemic in the public sector?

"It's a public relations battle more than anything else," he said. "People like to eat the same food, and they like what they eat, and that's hard to change."

Because of notably higher rates of diabetes in rural counties, Mr. Murtha has funneled federal funds for diabetes education to rural hospitals. Low incomes, lack of public transportation and scant medical resources all contribute to the epidemic.

Though sticking to a healthier diet has been difficult, Mrs. Torch, haunted by diabetes' impact on her family, has shed 50 pounds since diagnosis by walking daily and counting the carbohydrates in her diet.

Mrs. Torch receives Medicare and public assistance, including $284 a month in food stamps, but the disease sometimes leaves her depressed and even in tears.

"Food doesn't come cheap, and things with fewer calories cost even more," she said. "It's hard. It's rough. I eat hot dogs, and sometimes I have to eat beans.

"But you have to take care of it if you want to live."

Huge burden on individuals

Beyond the burden that the disease places on families, the cost of diabetes to the health-care system is staggering.

According to the CDC, the annual health-care costs for each person with diabetes is $13,243. For a person paying full cost, that equates to $7.45 an hour for each of the 1,777 hours of the average American's work year -- or $1.60 an hour more than minimum wage.

Last year the cost of health care for diabetes was about $132 billion, including $40 billion in indirect costs from disability, work loss and premature death, according to the CDC and the ADA. Although the total represents about 10 percent of the nation's health-care spending, some believe it has an even larger impact on the nation's health-care bill.

The highest rate of diabetes hospitalizations in southwestern Pennsylvania was for African-Americans, with a rate 3.1 times higher than for whites.

Fayette County reported especially high hospitalization rates for lower-extremity amputations and end-stage renal disease, with a diabetes death rate almost 50 percent higher than the state average.

Eleven percent of Fayette County's adult population has diabetes, said Cheryl Roberts, a registered nurse who helped launch a diabetes-education program at Uniontown Hospital in November, with aid from the University of Pittsburgh Diabetes Institute and funding through Mr. Murtha.

But resources to assist a mostly low-income rural population in managing the disease remain limited. Fayette has only 36 primary-care physicians and no full-time endocrinologist.

"There are a lot of desperate things here," Ms. Roberts said. "It is a low-income area with a lack of jobs, and a lot of people without insurance."

Hopelessness can reign. Many patients, she said, have dealt with job loss, other health problems and daily struggles to make ends meet. Many view diabetes as another problem over which they have no control.

"The biggest challenge is getting the population to realize they can make changes," she said.

Increases in the numbers of obese people are driving the epidemic. In Pennsylvania, one in four adults was obese in 2005, up from 16 percent in 1995, according to the state Department of Health.

A 'Coca-Cola-ized' nation

"We're a sedentary society with fast food, the 'Big Gulp,' and super-size everything," said Donna Rice, president of the American Association of Diabetes Educators. "People would rather take a pill than walk. And when they cut programs in school, what do they cut? Physical education."

Advertising campaigns peddling fat- and sugar-laden foods; sedentary lifestyles in front of computers, television sets and video games; the lack of prevention programs; and the dearth of endocrinologists, nurses and diabetes educators, especially in rural areas are factors feeding the epidemic.

"Let's face it, we made this epidemic," said Linda Siminerio, executive director of the Pitt Diabetes Institute and former president of the American Diabetes Association.

Other countries are becoming Westernized -- or as she describes it, "Coca-Cola-ized" -- leading to rising numbers of people with diabetes. Indeed, the epidemic has gone global.

The International Diabetes Federation said the disease affects 246 million people worldwide, with projections that it will skyrocket out of control to 380 million within 20 years if nothing is done.

Worldwide, diabetes already kills 3.8 million people each year, equalling the death rate of HIV/AIDS.

"Diabetes is fast becoming the epidemic of the 21st century," IDF President Pierre Lefebvre said.

Dr. Siminerio said patients are hungry for information about diabetes and methods to control it. Once people acquire management skills, control is simpler and more successful, she said.

Better control can help lower crucial benchmarks such as hemoglobin A1C, a test of average blood-glucose levels over several months. Every percentage drop in A1C reduces the risk of eye, kidney and nerve damage by 40 percent. That, along with lower blood pressure and cholesterol, can reduce the risk of heart attack and stroke, the ADA says.

Although expensive, technology also makes control easier. New types of oral medications and insulin are available, along with upgrades in insulin pumps and more accurate glucose monitors that use less blood and give faster results.

So tight control is feasible for those who can afford medications and technology and use them wisely. But only 60 percent of people with diabetes in Pennsylvania test their blood sugar even once a day, the state Department of Health says.

"There are all the tools you need to live a good, healthy life," said Dr. Barry Ginsberg, a physician and diabetes consultant. "It may not be as easy as you want it to be, but we are at the point where almost everyone can be in control."

But to achieve control, patients must put diabetes first in their lives, at least until management skills are learned, he said.

Even then, maintaining normal blood-glucose levels can be a frustrating hourly puzzle.

"There is no quick fix," Dr. Siminerio said. "I wish there were a magic bullet, but there isn't."