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Collegiate Case Study

HS2002-01

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Diabetes

The diabetes way of life Diabetes: A lesson in living Blood-vessel inflammation may signal diabetes, stroke Young type 2 diabetics face severe problems Companies seek alternatives to injected insulin Cooking up a balance

With over 17 million American afflicted and over 30 million projected by 2050, diabetes has become an alarming problem in this country. In the past it affected primarily older people but because of our sedentary life styles and poor eating habits younger generations are now suffering. This case study will focus on the disease, those who are affected by it, how to cope with it and promising new research and developments.

Cover story

The diabetes way of life Americans with disease learn to eat well, exercise

In trial, drug curtails diabetes Researchers weigh in on soaring diabetes rates Cell infusion is a ‘miracle’ for diabetic Damage often precedes diabetes detection —By Anita Manning

Case Study Expert: Francine Ratner Kaufman, M.D.

By Anita Manning Ted DeLeon’s family is plagued by diabetes on all sides. His parents, aunts and uncles and seven of nine siblings have it. Yet, when it came to him, he didn’t recognize it. “I was thirsty all the time. I gained 30 pounds over summer, was going to the rest room a lot at night,” he says. When, by chance, he saw an article about diabetes symptoms, “I said, shoot, that’s me.” He went to a doctor who tested the level of sugar in his blood. Normal is 70 to 149. DeLeon’s reading was 360.

President, American Diabetes Association

“I was almost on the verge of a diabetic coma.” DeLeon’s story is one that is becoming all too common in the USA. An estimated 17 million Americans have diabetes — an increase of nearly 1.5 million in two years. Of these, nearly 6 million are undiagnosed, yet the disease is silently at work in them, damaging blood vessels, nerves, eyes, heart, kidneys, legs and feet. The American way of life — too much food, too little exercise — has contributed to an epidemic of diabetes that is striking people of all ages. Even adolescents are

being diagnosed with type 2 diabetes, a form of the disease usually seen only in midlife. Once diagnosed, diabetes becomes a way of life for the patient and his family. While diabetics may live long and active lives, the disease is chronic and incurable, and may lead to symptoms that can cause disability and death. Type 2 diabetes is caused by the body’s inability to use efficiently the hormone insulin, which helps convert sugar into energy. Up to 95% of people with diabetes have type 2. Type 1, or juvenile diabetes, occurs when insulin-producing cells in the pancreas are destroyed. Type 1, which strikes one in every 400 to 500 children and adolescents, requires daily insulin injections. Type 2 diabetes is mushrooming in the USA. Most affected are minority communities, where a combination of lifestyle and genetics combines to increase risk. DeLeon, 54, who is Mexican-American, and his wife, Debbie, 48, who is Native American, are well aware of that and are spreading the word in their communities in Lansing, Mich., through an ethnic alliance that focuses on access to medical care.

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AS SEEN IN USA TODAY LIFE SECTION- TUESDAY - April 16, 2002 - 1D $14.95). “This is because everything you do affects your blood sugar levels.” The weight connection For Sandra Henson, 50, of Beaumont, Texas, diabetes meant major changes in her eating habits. “In southeast Texas, we eat a lot of rice, and I had to change to brown rice, change portion size, always watching to not eat too much at one time,” she says. Now, “I’ve lost weight, yes, but I’ve still got a long way to go.”

By Al Goldis, USA TODAY

She’s not worrying about her figure out of vanity. Being overweight reduces insulin sensitivity in people with diabetes, and it increases the risk of developing the disease in the first place. Because exercise has been found in several clinical studies to improve control of blood sugar, Henson, who rarely worked out before she was diagnosed, has become faithful about going to the gym.

Ted and Debbie DeLeon walk their dog, T’Tonka, Saturday, March 16, 2002, in Bancroft Park in Lansing, Mich. Ted was diagnosed with diabetes nine years ago and exercises every day with a brisk walk with the dog in a large park adjacent to their home.

“Being indigenous,” DeLeon says, “we’re way ahead of the rest of the population in terms of prevalence.” Debbie says she doesn’t have diabetes, “yet,” but it’s “rampant in my family. It has been devastating. Many have not made it to their 50s.” Diabetes is so common among American Indians, affecting more than 25% of the population in some tribes, that casinos and public buildings on reservations are equipped with hazardous waste disposal boxes mounted in rest rooms for safe disposal of insulin syringes and lancets used in testing blood. While genes may set you up for diabetes, Ted DeLeon says, it “kicks in when you gain a lot of weight and you don’t exercise. Where our family’s ancestors came from in Mexico, they don’t have it. Why? They eat beans and tortillas. Meat is a treat. There’s no McDonald’s. They work a lot (physically), and we don’t.” By watching his diet and walking — or being walked by — his 90-pound dog, T’tonka, every day, DeLeon has successfully kept his blood sugars under control. But for many people, managing diabetes is a complex balancing act that involves monitoring blood sugar levels two or more times a day, gaining an understanding of how foods interact with metabolism and how exercise affects blood sugar levels. Many diabetics take medications and some require insulin injections. “Diabetes, perhaps more than any other chronic disease, must be managed in large part by the patient,” says biologist and medical writer Gretchen Becker of Halifax, Vt., in the introduction to her book, The First Year: Type 2 Diabetes (Marlowe & Co.

But it’s not always easy. “I travel a lot, and sometimes I work late. When I get home I’m tired, and I don’t want to exercise. You have to discipline yourself and, hopefully, get other people to motivate you.” Like many new diabetics, she attended diabetes education classes to learn such survival skills as what to do if her blood sugar level plummets, how to cook without added fat, the difference between complex and simple carbohydrates and much more. Family members play an important supporting role in diabetes management, experts say, and that may require sacrifices of their own. No more ice cream in the freezer. Fewer rich dinners in fabulous restaurants. Less drinking. Constant attention to diet and exercise. And, in some cases, it means tending to the needs of a patient whose feet have been amputated or whose vision is lost. The demands of the disease on patient and family can lead to depression, marital discord and other stresses that John Zrebiec, associate director of mental health services at the Joslin Diabetes Center in Boston, calls “diabetes burnout.”

The emotional impact of diabetes and its effect on the family may require professional help, he says, identifying three specific points that send patients to a counselor: “We tend to see people when they’re newly diagnosed, when something about their diabetes care is going off track — there’s frustration, depression, anxiety, it’s not going smoothly — and third, is when there is the onset of long-term complications of diabetes. The most common diagnosis we see is depression.” People with diabetes are four times more likely to be depressed than non-diabetics, Zrebiec says. “I don’t know of research on how it affects the rest of the family, but I wouldn’t be surprised if they have more depression, too.” While there may be a physical explanation for the increased

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Diabetes AS SEEN IN USA TODAY LIFE SECTION- TUESDAY - April 16, 2002 - 1D rate of depression, he says, it’s clear the psychological cause is “a feeling of helplessness,” he says. “There are many times in trying to live with diabetes that you feel out of control and helpless. There are times you can do 110% of what you’re asked to do and still have blood sugars that make no sense.” Knowing your body Still, many people manage to balance the demands of the disease to enjoy full, happy and healthy lives. One of these is Gabriel Caro, a Boston Web site developer. At 6foot-1, a fit 174 pounds and only 29 years old, he doesn’t fit the stereotype of an overweight, middle-aged diabetic. Caro was training for a marathon when he was diagnosed two years ago with type 2 diabetes. While he has to remain ever vigilant, he says, a combination of medication and a lot of exercise keep his diabetes under control, allowing him flexibility to commit the odd dietary indiscretion without serious repercussions. “I will never let something like having diabetes get in the way of me enjoying my life,” he says.

“There are times when I know I should not be having a glass of wine or piece of cake, but I will have it.” He refuses to feel guilty. “Diabetes comes with this mystique around it. People are incredibly afraid of making a mistake or not eating well, or they just punish themselves for not exercising,” he says, but “it’s OK and natural and human to enjoy life and food. Ultimately, the most effective technique of controlling your disease is approaching it from different levels, physically, spiritually and emotionally. It’s a matter of quality of life. Yes, you have to watch what you eat, and you have to exercise, but you should view those things as positive.” Living with diabetes means a lot of reading, he says. “You have to understand your metabolism and how your body works, then you have to read about food and the properties of food, how to eat in proportions, the correct amounts of food, how to space your meals,” he says, but there is a benefit that others who don’t have diabetes may not experience. “You also have to study yourself a lot,” he says. “I think that among other things, it really tunes you in and makes you aware of your body.”

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AS SEEN IN USA TODAY LIFE SECTION- TUESDAY - April 16, 2002 - 7D

Diabetes: A lesson in living Diabetes can’t chill an adventurous Will By Anita Manning Will Cross wants the world to know that diabetes doesn’t have to mean disability. To prove that, Cross, who was diagnosed 25 years ago at age 9 with type 1 diabetes, is getting ready to trek across the Antarctic to the South Pole. The expedition will set out in November, with a goal of reaching the pole by New Year’s Day. Last year, Cross went to the North Pole. He also has climbed several mountains, including Alaska’s Mount McKinley, the tallest peak in North America, and taken part in expeditions to the Sahara, Patagonia and India’s Thar Desert. On his latest mission, the “Ultimate Walk to Cure Diabetes,” his aim is to raise money for the Juvenile Diabetes Research Foundation’s efforts to find a cure and to show others, especially children, that there is no reason diabetes should keep them on the sidelines. Role model: Will Cross’ trek to the North Pole last year and his preparations for the South Pole in November are

“I hope to inspire younger kids and their twofold: to raise money for the Juvenile Diabetes Research Foundation to find a cure and to let youth know they families who are wondering whether their can have fulfilling lives. kid can participate in school activities and sports,” Cross says. “I played sports all through school, but people are very hesitant to include the diabetic, because what if your blood sugar well if you’re going to live long,” he says. “It becomes a lesson in suddenly goes low? What if you need medication? I was always how to manage what you eat, to test your blood, exercise for at striving for independence. If you don’t, you don’t get to least an hour, four or five days a week.” How well that is accomplished, especially early on, is critical, he says. “Research participate.” shows the better you manage during your first year of diagnosis, Type 1 diabetes, which affects 5% to 10% of the 17 million the better off you are, long range.” diabetics in the USA, results from destruction of insulin-producing On his treks, he works with the University of Pittsburgh on cells in the body. It usually is diagnosed by early adulthood and requires daily insulin and careful monitoring of levels of blood studies of diabetic metabolism and how a diabetic might react to a 7,000-calorie-a-day diet and 12 hours of exercise pulling a 200glucose, or sugar. pound sled. “That’s exercise and eating in the extreme, but it’s Cross, who wears an insulin pump that delivers a constant relevant to the newly diagnosed diabetic, because it gives a brutal supply of the hormone to his body, says he has never let his understanding of how the body will manage under those illness stand in the way of his explorations. Now 34 and the father conditions,” he says. of four, his life is a series of adventures, from his day job as “If you can manage under this environment, you certainly can principal of the Alternative School in Pittsburgh, where he works with students with behavior problems, to his expeditions in in high school or at work.” hostile climates. For details on the Ultimate Walk to Cure Diabetes, check Diabetes is a disease that requires patients to “be fit and eat www.curewalk.com

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AS SEEN IN USA TODAY LIFE SECTION- TUESDAY - June 18, 2002 - 9D

Blood-vessel inflammation may signal diabetes, stroke Other highlights from the diabetes meeting:

By Anita Manning SAN FRANCISCO — Diabetes researchers studying the mechanisms that lead to chronic illnesses are zeroing in on inflammation as a major factor in both diabetes and heart disease. Scientists have recently noted that substances which signal inflammation, called inflammation markers, can be found in the blood of patients who have diabetes, as well as of those who have atherosclerosis, or hardening of the arteries, in which chronic inflammation of blood-vessel walls creates lesions that rupture, form clots and lead to stroke. Now, data presented here at the American Diabetes Association suggest that inflammation is part of the disease process in both conditions, and that these inflammation markers can be useful in predicting who will develop diabetes and which diabetics may suffer from heart disease. Treating inflammation may be a way to prevent both diseases, says endocrinologist Paresh Dandona of the State University of New York-Buffalo. Dandona reported on research that shows a drug called rosiglitizone, one commonly taken by adults with diabetes to boost insulin sensitivity, appears to have antiinflammatory properties. That means treating diabetes with these drugs may produce two benefits: increasing insulin response and decreasing the risk of atherosclerosis. Rosiglitizone, and probably other drugs in the same class, Dandona says, “can not only treat high glucose (sugar) levels in diabetes, they may actually prevent the major cause of death in diabetes.”

• The GlucoWatch Biographer, a wristwatch-like device that tests blood sugar levels through the skin, appears to work in children as well as in adults, research suggests. A study in 40 children ages 7 to 17 who have type 1, or juvenile, diabetes found that automatic glucose monitoring significantly improved control of blood sugar. The device is licensed only for adults, but the developer, Cygnus, is seeking Food and Drug Administration approval for its use by children. • An international survey of 2,702 people with diabetes finds that 60% say they’re not worried about such long-term complications as blindness or limb amputation, although studies show that if untreated, 74% of people with diabetes will develop a complication that could lead to blindness, kidney failure or lowerlimb amputation. The study by the International Diabetes Foundation and Lions Clubs International Foundation also found a fatalism that researchers found especially disturbing. “Over 40% think nothing they do will change the course of their disease,” says James Gavin, senior scientific officer at the Howard Hughes Medical Institute. “That’s wrong. We can prevent or delay all these complications. The fact that they don’t know that shows we have enormous work to do.” The study points to the need for better education, says Croatian endocrinologist Zeljko Metelko, vice president of the International Diabetes Federation-Europe. “Enormous amounts of money are spent on research, and enormous amounts are spent on treatment,” he says, “but the transfer of knowledge to physicians and patients is lacking.”

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AS SEEN IN USA TODAY LIFE SECTION - MONDAY - June 17, 2002 - 7D

Young type 2 diabetics face severe problems with type 2 diabetes before the age of 17. She reported:

By Anita Manning SAN FRANCISCO — The first long-term study of children diagnosed with type 2, or “adult-onset” diabetes, shows that as young adults, many suffer from severe complications, including kidney disease, miscarriages and death. The study, though small, is ringing alarm bells for researchers here at a meeting of the American Diabetes Association, giving weight to predictions that a growing incidence of type 2 diabetes in children could have catastrophic health consequences in years to come. Type 2 diabetes is the most common form of the disease, affecting at least 90% of the more than 17 million Americans with diabetes. It is associated with obesity, lack of exercise and genetics, and, until about 20 years ago, almost never occurred in teens or children. Unlike type 1, or juvenile, diabetes, type 2 is most often detected in middle age or older, but it is increasingly being found in children, especially among ethnic minorities, and has become a “dramatic and very alarming fact of our lives,” says Eugene Barrett of the University of Virginia, vice president of the diabetes association. Because it is new in children and many doctors don’t look for it, many cases may be overlooked, experts say. In communities where there is a large Hispanic, Native American or black population, as many as 50% of newly diagnosed children have type 2, Barrett says. Heather Dean, professor of pediatrics at the University of Manitoba in Winnipeg, Canada, who presented her study on Saturday, found a high rate of diabetic complications in a group of 51 Native Americans, now ages 18 to 33, who had been diagnosed

• Three are on dialysis because of kidney failure. • One became blind at 26. • One had a toe amputated. • Of 56 pregnancies, only 35 resulted in live births. • Two died of heart attacks during dialysis. Another five died of causes unrelated to diabetes. Because her study was small and involved a genetically distinct group, Dean says, the findings can’t be applied to all children with type 2 diabetes. And, she says, the outlook may improve, thanks to advances in the treatment of diabetes in the past 15 years. “We’ve become much more aggressive in our treatment strategies,” she says. “My sense is the future is more optimistic, but this is the first group, and this helps us to realize this is a very aggressive disease with very serious long-term complications.” The reasons for the increase in children are not entirely known, but many experts believe inactivity, overeating and genetics are coming together to create a public health time bomb set to go off over the next two decades. “Obesity is pulling the trigger,” says pediatrician Silva Arslanian of the University of Pittsburgh School of Medicine. “Rates of obesity in children are escalating like a rocket. Two of five children are overweight, and some races are even more prone to be overweight.”

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AS SEEN IN USA TODAY LIFE SECTION - MONDAY - June 17, 2002 - 7D

Companies seek alternatives to injected insulin This is an AERx insulin delivery system, an alternative method of insulin administration.

By Anita Manning SAN FRANCISCO — Drug companies are making progress in efforts to bring needle-free insulin to people with diabetes, but they’re still years from the finish line.

degraded. “We’re able to control blood glucose, probably for the first time, with an oral insulin preparation that is ingested,” says researcher Stephen Clement of Georgetown University, who presented results of studies on the Nobex drug. The product is early in development, he says, but is “very feasible.”

Several studies reported here Sunday at a meeting of the American Diabetes Association show that research in alternatives to insulin injections is advancing rapidly, says Christopher Saudek of Johns Hopkins School of Medicine, president of the association. But he cautions that “each is at a different stage in development, and people are well advised to take advantage of what is available today” to manage diabetes.

* Insulin patch. A two-step system that uses a batterypowered sticky patch to open skin pores, then deliver insulin through a second patch, is being made by Altea Development Corp. In a small study, it provided a steady supply of insulin over 12 hours.

Of the estimated 17 million Americans with diabetes, about 3.7 million need daily insulin shots to keep levels of blood sugar on an even keel and to prevent such long-term complications as heart disease, blindness, kidney disease and amputations.

* Insulin mouth spray. Generex Biotechnology Corp.’s RapidMist allows insulin to be absorbed through cells lining the mouth. Generex researcher Pankaj Modi says the insulin spray was as effective in tests as fast-acting injected insulin.

Among developments: * Insulin pills. Nobex Corp. and Emisphere Technologies are taking slightly different approaches in developing insulin pills that can be absorbed through the digestive system without being

* Inhaled insulin. Five companies are racing to develop a fastacting form of insulin that can be inhaled into the lungs in liquid or powder form, but questions remain about its safety for long-term use.

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AS SEEN IN USA TODAY LIFE SECTION - WEDNESDAY - June 12, 2002 - 6D

Cooking up a balance New approaches help diabetics make tasty food By Anita Manning Last year, in the middle of a teenage whirl of high school, friends and sports, Emma Lowenstein’s life changed. The Chevy Chase, Md., teenager, now 15, was diagnosed with type 1, or juvenile, diabetes. Her mother says she never saw it coming. Emma had symptoms, she says, including weight loss and constant thirst, but diabetes “was so off my radar screen.” No one in the family had the disease. The Juvenile Diabetes Research Foundation says that’s common in about 90% of cases. “I knew one kid my daughter’s age with diabetes, but I knew nothing about it,” says Emma’s mother, Shelley Lowenstein. “We were so ignorant.” Not anymore. The diagnosis has meant changes, not only for Emma — who has learned to test her blood several times a day, inject insulin and balance diet and exercise — but also for her family. By Steve Barrett for USA TODAY

“We didn’t know if Emma could ever eat cookies again,” her mother says. She and Emma pored over nutrition labels in the grocery store, combed through cookbooks and went online looking for information. “We were always a family that loved to cook,” she says. “My husband clips recipes. We eat out all the time.” Now the family’s dining choices are influenced by Emma’s need to eat a balanced diet on a daily schedule. As a diabetic, “you learn to live by the clock, which we’ve never done,” Lowenstein says. “That means you have to get up at a certain time, eat at a certain time, have a mid-morning snack at a certain time . . . “ People with diabetes need to eat frequently, generally three meals and at least a couple of snacks, to keep blood sugars on an even keel. That means keeping portion sizes small and eating a variety of foods in moderation, says Carol Guber, whose book, Type 2 Diabetes Life Plan (Broadway Books, $25) is being published this week. While most dieters obsess over fats and calories, diabetics need to limit carbohydrates, which greatly affect blood sugar. Guber says most adults can consume 45-75 grams of carbohydrates per meal, depending on age, weight and activity level. (There are around 15 grams of carbohydrates in a slice of bread or half a banana, and about 41 per cup of pasta. A 2-ounce package of strawberry Twizzlers has 54 grams.) Carbohydrates are nutrients that are released into the

Big adjustments: Shelly Lowenstein and daughter Emma, 15, adapt their favorite recipes to suit Emma’s diabetic needs. She often needs a bedtime snack to get her through the night, when sugar levels tend to drop.

bloodstream in the form of glucose, a simple sugar that fuels cells. Insulin is a hormone that allows cells to use this sugar fuel, but in juvenile diabetes the body’s insulin-producing mechanism is destroyed. Patients have to take insulin shots every day. In type 2 diabetes, insulin is produced, but it’s not used efficiently by the body, resulting in high blood sugars. Type 2 diabetes often can be managed with drugs and diet. In either form of the disease, diet plays a crucial role in balancing blood sugars. Food and family eating habits have as much to do with culture and social interaction as with nutrition, Guber says. When she was diagnosed with diabetes nearly five years ago at age 50, she says, “I thought it was going to separate me from everyone.” Food was “part of the community I lived in,” says Guber, who taught nutrition and food preparation at New York University for many years. She feared the need to watch every morsel would separate her from her peers. It hasn’t, she says. In fact, she says she’s able to incorporate new dining habits seamlessly into everyday life — whether eating at home or in restaurants — by corralling her cravings, losing weight

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Diabetes AS SEEN IN USA TODAY LIFE SECTION - WEDNESDAY - June 12, 2002 - 6D and developing eating patterns that would be good for all Americans.

cater to them,” Lowenstein says. “She said those people should get special cookbooks.”

“Everybody should be eating as if they have diabetes,” Guber says. “It’s a healthy way of eating.”

There are plenty of “special cookbooks” for diabetics, including dozens published by the American Diabetes Association (ADA), (www.diabetes.org). “People with diabetes are starving for information,” says Chris Smith, author of Cooking with the Diabetic Chef ($19.95), one of the ADA’s publications.

When Emma Lowenstein was diagnosed with diabetes, her mother set out to find recipes that would be good for Emma and that the whole family would enjoy. That soon proved frustrating, she says, because newspapers, magazines, cooking shows and even cookbooks often fail to provide complete nutritional information. Lowenstein set out to change that, launching an advocacy group called Per Serving (www.per-serving.org) to try to persuade newspaper food editors, through a letter-writing campaign, to include per-serving food facts for all recipes. The effort has won the support of the American Association of Diabetes Educators, the American Cancer Society, American Heart Association and other groups. “I’m a very practical person, and I want to do anything I can to make her day-to-day life easier,” Lowenstein says.

A Culinary Institute of America-trained chef and a type 1 diabetic, Smith has developed cooking methods that he demonstrates across the country for audiences made up of diabetics, heart patients and others interested in healthy eating. At a recent event at the East Texas Medical Center in Tyler, where about 70 audience members were expected, a crowd of 800 showed up, most of them non-diabetic, he says. Smith will attend the upcoming ADA annual meeting, starting Friday in San Francisco. While most of the hundreds of presentations will focus on the latest medical advances in diabetes, Smith will hold cooking seminars on such topics as summer salads, vegetarian cuisine and grilling. There’s nothing magic about a diabetes-friendly diet, he says.

“When reputable newspapers run headlines all the time about diabetes, obesity, heart disease and cancer and don’t give us this information on their food pages, they’re only giving us half the story.” So far, she says, the reaction from editors has been mixed. Many big-city papers, including The Washington Post, The Philadelphia Inquirer, Chicago Tribune and San Francisco Chronicle do print complete nutrition information with recipes, but “there is still a lot of resistance,” she says. One editor wrote to say her paper provides information on calories and fat in recipes; anything more is important only to “people with special needs, and she can’t

“What I teach is actually cooking lessons, from pan searing to roasting to wok cooking to poaching,” he says. “People are compromised nutritionally. I’m fighting a tidal wave. I want to teach people to eat healthy.” By exercising portion control and making simple changes in cooking methods — roasting instead of deep-fat frying, for instance, or using marinades and spices to flavor foods instead of heavy sauces — people with diabetes or other health problems can eat just about anything, he says.

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AS SEEN IN USA TODAY LIFE SECTION - THURSDAY - May 30, 2002 - 8D

In trial, drug curtails diabetes By Anita Manning A two-week treatment with an experimental immunesuppressing drug halted progression of diabetes in newly diagnosed patients for at least a year, scientists report today.

If results are confirmed in larger studies, the drug could be a “major contribution” to diabetes prevention, says Jay Skyler of the University of Miami.

Skyler, director of a large diabetes prevention study, reports in a second journal article that in a study of 339 people at high risk of developing type 1 diabetes, In a study in today’s New England Journal of insulin injections did not prevent the disease. Medicine, researchers at Columbia University say Type 1 diabetes: they followed the course of illness in 24 patients, The data, initially reported last year at a meeting ages 7 to 27, who recently were diagnosed with of the American Diabetes Association, failed to About 5% to 10% of type 1 diabetes, a form of the disease that occurs confirm smaller studies that indicated insulin the nation’s estimated when the insulin-producing cells in the pancreas injections might preserve the ability of pancreas 17 million diabetics are destroyed by the body’s own immune cells to produce insulin by giving the cells periods have type 1, or juvenile, system. of inactivity and making them less likely to be diabetes, caused by the targeted for destruction by the immune system. body’s inability to They found that the drug halted destruction of produce insulin. insulin-producing cells in nine of the 12 treated “We’d hoped we’d find something that would patients, while 10 of the 12 untreated patients have been a help to the people at risk for had significant decline in insulin production. diabetes,” Skyler says. Because so much is known about insulin and its safety, he says, “if we had hit with this, we would have The experimental drug is safer than other immunebeen thrilled.” suppressants because it targets only specific cells, eliminating dangerous side effects on other organs or tissues, says its The study shows the value of clinical trials, Skyler says. “Small developer, Jeffrey Bluestone of the University of California-San studies might give us hints of what might be right,” but their Francisco. Its beneficial effects continue beyond treatment, he results need to be confirmed in larger studies. says. “It seems to re-educate the immune system, for a while at least,” he says. A two-year trial involving 80 patients is scheduled to begin within a few weeks, Bluestone says.

The second part of the Diabetes Prevention Trial, a study to determine the effect on diabetes prevention of oral insulin, which works through a different mechanism than injected insulin, should be completed next year, Skyler says.

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AS SEEN IN USA TODAY LIFE SECTION - WEDNESDAY - May 15 2002 - 5D

Researchers weigh in on soaring diabetes rates By Anita Manning WASHINGTON — More than 17 million Americans have diabetes, and if rates continue to soar, there could be 30 million suffering from the chronic, sometimes fatal, disease by 2050. Diabetes is “a side effect of prosperity” that is growing alarmingly around the world, says Christopher Saudek, director of the diabetes center at Johns Hopkins University. “Any nation that increases its body weight is going to increase its diabetes.” In the USA, he says, diabetes rates have risen 6% a year for the past decade. Saudek, president of the American Diabetes Association, spoke Tuesday at a briefing by the Journal of the American Medical Association on its theme issue on diabetes, published today. Among reports: • Differences in the long-term diabetes complications among ethnic groups may have more to do with genetic susceptibility than access to good medical care, say researchers at Kaiser Permanente in Oakland. An analysis of data on 62,432 diabetic patients enrolled in the Kaiser Permanente HMO in Northern California found that whites have higher rates of heart attack than blacks, Asians and Latinos, while minorities experience more kidney failure than whites. Rates of congestive heart failure and stroke were similar for blacks and whites but were lower for Asians and Latinos. The incidence of limb amputations was similar among blacks, whites and Latinos, but in Asians, the rate was a startling 60% lower than that of whites. The disparities suggest the complications have “genetic underpinnings,” Kaiser researcher Joe Selby says.

• Children with diabetes are more likely to suffer dangerous highs and lows in blood sugar levels if they are underinsured, have had erratic blood sugar level swings in the past three months or have psychiatric problems that could cause them to skip insulin injections. A study by researchers at the University of Colorado-Denver looked at 1,243 diabetics under age 20 and their incidence of severe high blood sugar, called ketoacidosis, and very low blood sugar levels, or hypoglycemia. Either condition can cause coma and death. The researchers found that 80% of the episodes occurred in 20% of the children, suggesting that children at greatest risk can be identified and targeted for extra help. Researchers estimate the cost of treating ketoacidosis and hypoglycemia in diabetic children in the USA at more than $100 million per year during the late 1990s. • One or two drinks of alcohol a day improve insulin sensitivity in older women, who are at increased risk of diabetes after menopause. In a study of 63 postmenopausal, non-diabetic women, researchers at the Human Nutrition Research Center, part of the U.S. Department of Agriculture in Beltsville, Md., found that those who had one or two drinks before bed — they were given grain alcohol mixed with orange juice — each night for eight weeks had better insulin sensitivity and lower levels of triglycerides, a type of fat, than non-drinkers. Earlier studies have found that moderate drinking reduces heart disease risk, researchers say. The new data show a similar effect on diabetes risk. • Women who are born small may be at higher risk of developing gestational diabetes, a transient form of the disease, during their first pregnancy, says a report from the University of Colorado and the University of Virginia. Gestational diabetes often disappears after pregnancy, but it is a risk factor for later development of diabetes in the mother. The finding suggests that susceptibility to diabetes may be “preprogrammed in uteruo,” researchers say.

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AS SEEN IN USA TODAY LIFE SECTION - THURSDAY - May 16, 2002 - 8D

Cell infusion is a ‘miracle’ for diabetic Before the procedure, Schwendinger had been unable to stabilize her blood-sugar level, no matter what she did. Now, it’s always on target. She no longer needs insulin shots because her body is producing the hormone. She eats what she wants, when she wants, and even has a glass of wine now and then. She has some side effects from the immune-suppressing drugs she takes daily to keep her body from rejecting the transplanted cells, such as edema, high blood pressure and a low white-bloodcell count. She says the trade-off is worth it. “I’m one of the first pioneers,” says Schwendinger, diagnosed when she was 7. The procedure has “a long way to go and quite a bit of research has to be done, but I think it’s fantastic. All those years, that was my one prayer: ‘Please, God, take this disease away from me.’ “ Schwendinger and other pioneers who have undergone isletcell transplantation are in Washington, D.C., today to kick off the annual meeting of the Juvenile Diabetes Research Foundation and lobby Congress for funding to help find a cure for diabetes. Juvenile diabetes, also called type 1, affects about 1 million Americans. Usually diagnosed by early adulthood, it results from the loss of insulin-producing islet cells in the pancreas. Because their bodies produce little or no insulin, type 1 diabetics require daily injections to stay alive.

By H. Darr Belser, USA TODAY

Sigrun Schwendinger is a diabetic but is off insulin injections after undergoing an experimental procedure. She works in the admissions office of the Landon School in Bethesda.

Robert Goldstein, chief scientific officer of the Juvenile Diabetes Research Foundation, says fewer than 80 people have undergone the process, in which doctors remove islet cells from cadavers and infuse them through a thin tube into recipients.

By Anita Manning

Usually two pancreases are needed to harvest enough islet cells, and a lack of the donated organs is one reason more islet-cell transplantations have not occurred.

For 50 years, Sigrun Schwendinger of Potomac, Md., coped with diabetes. She gave herself multiple insulin injections every day, tested her blood-sugar levels frequently and paid constant attention to her diet and exercise.

For people whose diabetes has caused complications, such as vision or hearing loss, or who can’t control wide swings in bloodsugar levels, “to be able to change the course of their disease is akin to a miracle,” Goldstein says.

That changed in February 2001, when Schwendinger got the second of two infusions of insulin-producing pancreatic cells in an experimental procedure at the National Institutes of Health.

But because transplant patients have to take drugs every day, the procedure isn’t for everyone

The process, developed by Canadian scientists and reported two years ago, is being duplicated in medical centers around the world.

“This is not the ultimate answer,” Goldstein says..

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AS SEEN IN USA TODAY LIFE SECTION - WEDNESDAY - April 17, 2002 - 8D

Damage often precedes diabetes detection By Anita Manning The complications of diabetes come on slowly and stealthily, say experts from the American Association of Clinical Endocrinologists, who on Tuesday staffed the first USA TODAY online chat on the illness. “It may take as long as 10 or 15 years for complications to develop,” says AACE president Rhoda Cobin of Mount Sinai School of Medicine in New York, in response to a reader’s question. “Often people who have type 2 diabetes (the form usually diagnosed in midlife) have actually had it for many years before it is detected, so as many as 50% already have complications at the time of detection. Neuropathy (nerve damage), eye, kidney and heart disease may all occur.” The diabetes hotline drew questions from 708 readers around the world. Cobin — and endocrinologists Paul Jellinger of the University of Miami School of Medicine, and Om Ganda of Harvard Medical School and the Joslin Diabetes Center in Boston, fielded questions on diagnosis, medications, diet and complications of diabetes, which affects 17 million Americans. A sampling: Q: Does heavy drinking of liquor affect the blood sugar? Is one type better than others? — Lake Worth, Fla. A: Too much alcohol poisons the liver and predisposes the body to hypoglycemia (low blood sugar). But it also contains calories, so it can make the sugar go up and put on weight. Alcohol is alcohol, but some drinks, like sweet wines, beer, etc., have more calories and sugar in them. — Cobin

Q: My daughter who is 20, has had adult-onset diabetes since the age of 16. She is at present on insulin. How long a life can I expect for her? Will she be able to marry and have children normally? — Dubai, United Arab Emirates A: It depends on how well controlled her sugar is. If it is under good control and she has no complications, she should be able to live a long life. Pregnancy likewise, but (it) requires very frequent testing to tightly control the blood sugar to make sure the baby has no problems. Please consult a specialist who is familiar with pregnancy in a diabetic before conception, if possible. — Cobin Q: If you have a strong family history for diabetes, is it recommended to start on medications before you have (it)? — Orlando A: Research is looking at that question, but the final word is not yet in. No recommendation for medication is at this time appropriate, but that recommendation may be with us in the near future. Stick with diet, exercise and weight loss (if obese) for now. — Jellinger Q: What is the status of a cure in the next five years? — Blairsville, Ga. A: The cure is not yet in sight, unfortunately. A number of studies are in progress. Islet-cell transplant looks more promising than before. Efforts are also underway in the development of a vaccine. — Ganda

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Behind the Story: A Reporter’s Notebook As the prevalence of diabetes increases around the world, the need for broader understanding of this disease and its impact on nearly every facet of society has grown.

Anita Manning

Diabetes affects the individual, the family, employers, insurance companies, the food industry, schools and government. Studies show changes in lifestyle may be as effective as medication in some cases, and promising new research is being done with islet cell transplantation and stem cells.

In order to bring together the diverse parts of this story, I rely on those who have diabetes to describe how it affects their own lives, supplementing that with information from scientists and

physicians. I call on diabetes experts for practical lifestyle advice for patients and families, and national health leaders for statistical and policy information. Underlying all this coverage is a belief that the more our readers understand about diabetes, the better prepared they will be to conduct their own lives and to influence public health policy. Anita Manning is a medical reporter at USA TODAY. She began working for Gannett in 1979 at the News Journal in Wilmington, Del., and has been with USA TODAY since 1983. She specializes in coverage of infectious diseases, vaccines, food safety and diabetes. Anita was awarded the C. Everett Koop Medal for Health Promotion and Awareness in 2001 by the American Diabetes Association. She received a degree in English, with a minor in journalism, from the University of Rhode Island in 1968, and now lives and works in Wilmington, Del.

Reprinted with permission. All rights reserved.

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Future implications:

For discussion

1. Why is the prevalence of type 2 diabetes increasing in the U.S.? 2. What are the most effective prevention strategies for type 2 diabetes? 3. How do particular types of inflammatory signals increase risk for diabetes cardiovascular disease? 4. For many people with diabetes, self-administering insulin is a daily, painful chore. What are the new insulin delivery technologies on the horizon? 5. Is there hope of developing a cure for type 1 diabetes?

1. There are now scientifically proven strategies to prevent or delay type 2 diabetes. How can health care providers better recognize those at risk for the disease and incorporate these proven strategies into clinical care? 2. What impact could new glucose monitoring devices, such as continuous monitors, have on the future of diabetes care?

About Francine Ratner Kaufman, M.D. President, American Diabetes Association Dr. Kaufman is currently a Professor of Pediatrics at the Keck School of Medicine at the University of Southern California; Director, Comprehensive Childhood Diabetes Center; and Head of the Division of Endocrinology, Diabetes & Metabolism, at Childrens Hospital of Los Angeles. Dr. Kaufman earned her undergraduate degree from Northwestern University and her medical degree from Chicago Medical School, where she was Valedictorian of her medical school class and won the Medical School Pediatric Award. Dr. Kaufman has received continual funding from the National Institutes of Health (NIH) since 1980, and has focused her work on many aspects of diabetes, including type 1 and type 2 diabetes prevention, the endocrinology of HIV infection, and galactosemia, a rare inborn metabolic error. Dr. Kaufman has been actively involved with the American Diabetes Association since 1978. The Association gave her the award for Outstanding Contribution to Children and Youth with Diabetes in 1996.

Additional resources Organizations: American Diabetes Association (www.diabetes.org) Juvenile Diabetes Research Foundation (www.jdf.org) American Association of Diabetes Educators (www.aadenet.org) American Association of Clinical Endocrinologists (www.aace.com) International Diabetes Foundation (www.idf.org)

Books: The First Year: Type 2 Diabetes (Gretchen Becker, Marlowe & Co) Type 2 Diabetes Life Plan (Carol Guber , Broadway Books) Cooking with the Diabetic Chef (Chris Smith) Referenced Web Site: Per Serving (www.per-serving.org)

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