Diabetes. H E A L T H Y P E O P L E L I B doctor or nurse about diabetes. 38 types of diabetes, but they all have. to do with the body’s inability to …

HEALTHY PEOPLE LIBRARY PROJECT
American Association for the Advancement of Science

Diabetes
The Science Inside

Diabetes: The Science Inside

HEALTHY PEOPLE LIBRARY PROJECT
American Association for the Advancement of Science

Published 2003 by The American Association for the Advancement of Science AAAS 1200 New York Avenue, NW Washington, DC 20005 Copyright 2003 by AAAS ISBN: 0-87168-689-9 All rights reserved Except for use in a review, no part of this book may be reproduced, stored in a retrieval system, or transmitted in any form, or by any means, electronic, mechanical, photocopy, recording, or otherwise, without prior permission of AAAS This booklet is a product of the Healthy People 2010 Library Initiative funded by the National Institutes of Health Grant 5R25RR15601 Any interpretations and conclusions contained in this booklet are those of the authors and do not represent the views of the AAAS Board of Directors, the Council of AAAS, its membership or the National Institutes of Health

TABLE OF CONTENTS
1 3 3 3 4 4 6 9 9 9 10 10 11 15 15 16 17 18 20 20 21 21 25 25 26 29 33 33 37 38 39 45 49 INTRODUCTION PART 1: WHAT IS TYPE 2 DIABETES? Healthy glucose levels Type 2
diabetes Symptoms of diabetes How diabetes affects the body Causes of type 2 diabetes PART 2: WHO HAS TYPE 2 DIABETES? Rising incidence of type 2 diabetes Uneven impact of diabetes Genetic reasons for the uneven impact The uneven availability of health care Other factors leading to the health disparity PART 3: HOW IS TYPE 2 DIABETES PREVENTED AND TREATED? Diagnosing diabetes Preventing and controlling diabetes Managing blood sugar Eating healthfully Getting exercise Monitoring your blood pressure Keeping cholesterol at healthy levels Diabetes treatment plans PART 4: HOW DO RESEARCHERS STUDY DIABETES? Discoveries through research Current lines of research The important role of volunteers PART 5: LETS TAKE CONTROL OVER TYPE 2 DIABETES How you can help Questions to ask your doctor or nurse about diabetes Taking part in research studies: What questions should you ask? RESOURCES BIBLIOGRAPHY GLOSSARY

INTRODUCTION
Diabetes means that your blood
sugar is too high Your blood always has some sugar in it because the body needs sugar for energy to keep you going But too much sugar in the blood is not good for your health There are several different types of diabetes, but they all have to do
with the bodys inability to process blood sugar Diabetes is a long-lasting, chronic disease that can lead to many difficult health problems Heart disease, kidney disease, blindness, and amputation are just some of the many complications of diabetes These problems can shorten the lifespan by many years and cause great misery Diabetes used to be untreatable If you had the disease, you most likely would die prematurely That changed in 1925 when researchers learned that diabetes can be controlled by injecting insulin This was not a cure, but it did allow people with the disease to live many years longer Diabetes was no longer as highly feared as it had once been But now there is grave new concern over diabetes The new concern is that the number of people affected by the disease is increasing at a
Adults and children from minority racial and ethnic groups are hit especially hard by diabetes

rapid rate The increase is occurring with one particular form of the disease called type 2 diabetes Over the past few decades there has been a big increase in the number of people diagnosed with type 2 diabetes both in the United States and around the world

Health experts say more than 11 million
Americans have been diagnosed with diabetes Probably 90 to 95 percent of all these diagnosed cases of diabetes are type 2 Experts also estimate that another 6 million Americans have diabetes but dont know it Type 2 diabetes is hitting especially hard among certain groups of Americans People at special risk for the disease include African Americans, Hispanics, American Indians, Alaska Natives, Asians,

Diabetes: The Science Inside
and other Pacific Islanders Elderly people and poor people also are at special risk People from these groups are more likely to get type 2 diabetes and also to suffer from the complications of the disease Diabetes has become the sixth leading cause of death in the United States On average, the risk of death for a person with diabetes is twice as high as for someone without the disease The toll from diabetes is greater than these numbers reveal, because health problems and deaths from diabetes are often credited to other causes Thats why diabetes has the nickname, the hidden disease The rise of type 2 diabetes is bad news Fortunately there is also some good news Modern research has discovered two important lessons about type 2 diabetes The first lesson
is that many cases of this disease can be prevented The second lesson is that for many people, the health complications of type 2 diabetes can be totally avoided or delayed for many years The purpose of this book is to provide basic information about type 2 diabetes: what causes it, how it affects the body, and how it can be prevented and treated This book is NOT a treatment guide, but it does offer general advice that can help you avoid type 2 diabetes and minimize the complications if you have the disease
Note to Readers: Boldface words, as well as some underlined words in sidebars, are defined in a glossary that begins on page 49

Diabetes in the US Population
Total population: 285 million Number with diabetes: 156 million Prevalence: 82 percent WHITES NON-HISPANIC Number with diabetes: 113 million Prevalence: 78 percent AFRICAN AMERICANS NON-HISPANIC Number with diabetes: 23 million Prevalence: 108 percent MEXICAN AMERICANS Number with diabetes: 12 million Prevalence: 106 percent OTHER HISPANIC/LATINO AMERICANS Almost twice as likely to have diabetes as non-Hispanic whites of similar age NATIVE AMERICANS AND ALASKA NATIVES About 28 times more likely to have diagnosed diabetes
as non-Hispanic whites of similar age ASIAN AMERICANS AND PACIFIC ISLANDERS Studies indicate that some groups within this population are at increased risk For example, Native Hawaiians appear twice as likely to have diagnosed diabetes as white residents of Hawaii Figures are for persons age 20 and over They do not include the approximately 123,000 cases of diabetes in children and teenagers Prevalence means number of cases per 100 people Data from Diabetes Statistics, National Institute of Diabetes and Digestive and Kidney Diseases NIH Publication No 99-3921, May 1999

Part 1: What is type 2 diabetes?
Healthy glucose levels
Sugar is a common nickname for diabetes, because it is an illness involving too much sugar in the blood The formal name is diabetes mellitus, which translates from Greek and Latin to passing through a lot of sugary urine Glucose is a form of sugar found in food When the body digests food, glucose moves into the bloodstream In response the body releases insulin, which is a hormone Hormones are chemicals produced by organs of the body to trigger activity in other locations The hormone insulin is released by an organ called the pancreas, and it triggers the
opening of body cells so that glucose may enter and be used for energy As glucose moves into body cells, the amount that remains in the bloodstream falls When it falls below a certain point, the pancreas releases another hormone called glucagon This hormone triggers the release of stored glucose from the liver Through the work of the two hormones, insulin and glucagon, the body maintains a stable level of glucose in the blood

Type 2 diabetes
There are several types of illness that fall under the name diabetes In all types, a persons body has trouble keeping blood sugar stable With type 2 diabetes, the cells resist the efforts of insulin to open them up and let glucose inside This is known as insulin resistance

Type 1 diabetes is most often diagnosed in people under age 30, while type 2 diabetes is most often diagnosed in older people

Diabetes: The Science Inside Symptoms of diabetes
The symptoms of all forms of diabetes are alike One symptom is having to urinate a lot Other symptoms include blurry vision, itchy skin or skin infections, sores that take a long time to heal, unusual thirst, tiredness, dizzy spells, nerve pain, and losing weight while being hungry all the time If
you have type 2 diabetes, you may have mild symptoms for many years before learning you have the illness You may have no symptoms but find out you have the disease after a screening test at the doctors office Diagnosis is important, even when symptoms are mild or absent Early detection can prevent the health problems that arise sooner or later from untreated type 2 diabetes

Type 1 diabetes is much less common than type 2
With type 1 diabetes, the pancreas no longer makes the hormone insulin Without insulin, cells do not open up to let inside the glucose that they need Researchers are trying to figure out what causes type 1 diabetes They are studying whether it might be caused by viruses, chemicals, stress, or even certain foods Whatever the trigger, it somehow upsets the immune system Normally, the immune system protects the body against outside invaders such as viruses and bacteria When the immune system gets confused, it can attack parts of the body itself With type 1 diabetes, the immune system attacks the insulinproducing cells of the pancreas Type 1 diabetes is most often diagnosed in people under age 30, so it is sometimes called juvenile diabetes However, adults can be
diagnosed with type 1 Type 1 affects a greater percentage of white Americans compared to Americans from racial and ethnic minorities

As the condition progresses in many cases of type 2, the pancreas also does not produce enough insulin More than 90 percent of all cases of diabetes are type 2 The disturbing increase in diabetes cases in recent years involves type 2 Type 2 diabetes is most often diagnosed in older people This is why it has been called adult-onset diabetes This label is no longer used, because it is misleading Young people can also be diagnosed with type 2 In fact, so many young people today are being diagnosed with type 2 diabetes that it is considered an epidemic

How diabetes affects the body
The problems of diabetes are caused by too much blood sugar, that is, too much glucose in the blood This creates a chemical imbalance in the body which increases the fats in the blood The imbalance damages the blood vessels, which are the pipelines through which blood travels to all parts of the body The damaged blood vessels become clogged and less able to carry blood This in turn harms body cells that depend on the bloodstream for food and oxygen The various organs of the
body func-

Part 1: What is type 2 diabetes?

tion poorly when their cells are starved in this way Damaged blood vessels in the eyes leak fluid, bleed, and swell Replacement blood vessels begin to grow, but they are fragile and may also bleed, causing further damage if untreated This can lead to blindness People with diabetes are at greater risk for heart disease A risk factor for heart disease is high blood pressure also known as hypertension High blood pressure occurs when the heart must use greater force than normal to push blood through the pipelines High blood pressure can damage the heart and further strains the blood vessels that have been damaged as a direct result of glucose imbalance With high blood pressure comes an increased risk for heart attack and stroke High blood pressure also stresses the kidneys, which filter the blood Damage to the kidneys leads to even higher blood pressure, resulting in a dangerous spiral As stated above, the chemical imbalance caused by too much blood sugar has an effect on cholesterol levels Cholesterol is a wax-like substance that circulates in the blood stream and plays an important role in several functions of the cells Improper
amounts of cholesterol can increase the risk for heart disease

Improper blood sugar also disrupts and damages the nerves The nerves are the networks of cells that transmit signals from all parts of the body to the brain and back Since the nerves go everywhere in the body, damaged nerves lead to problems throughout the body Despite all the extra sugar in the blood, not enough is getting into the cells that need it This is because insulin which triggers cells to open up and take in glucose is not present or is not working properly The body thinks the problem is a lack of glucose, so it raids the liver, where

A different disease has a similar name
When people talk about diabetes they usually mean diabetes mellitus — the subject of this book But there is another unrelated disease named diabetes It is diabetes insipidus, or water diabetes, and it is quite rare Only three in every 100,000 people in the United States are affected by it Diabetes insipidus occurs when the body does not make or properly store a certain hormone Without instruction from this hormone, the kidneys do not properly control the level of water in the blood and too much is turned into urine People with the disease
have to urinate a lot They are very thirsty, too, because their bodies want to replace all the lost water Treatment depends on the particular cause Sometimes a patient can simply drink more to make up for the water loss Sometimes a patient takes a drug to replace the missing hormone or to lower urine output Sometimes the disease goes away if the patient stops taking a medicine that causes diabetes insipidus as a side effect If diabetes insipidus is treated, there are no other problems to health

Diabetes: The Science Inside
glucose is stored It also breaks into muscle and fat cells that have stored glucose Without insulin, the released glucose still cannot be used by the cells that need it They stay deprived of the energy they need to keep working This uncontrolled type 2 diabetes creates trouble throughout the entire body and can lead to a long list of breakdowns in health People often do not make a connection between the illness called diabetes and these other health problems In fact, diabetes can be the terrible trigger A description of the many health problems linked to uncontrolled type 2 diabetes appears on page 27

Causes of type 2 diabetes
A key trigger for type 2
diabetes is overweight or obesity Obesity is defined as being more than 20 percent over ideal body weight Carrying extra fat appears to trigger insulin resistance, though researchers do not yet understand why What they do know is that more than three-fourths of all people with type 2 diabetes are overweight or obese

Diabetes can do a lot of harm to the body It can damage the blood vessels that carry food and oxygen to cells of the body It can damage the nervous system, which transmits signals to and from the brain And it can damage different organs of the body such as the eyes, the kidneys, and the heart

Part 1: What is type 2 diabetes?

James R Gavin III
Like my grandmother used to say, says Dr James R Gavin III, were digging our graves with our teeth Dr Gavin is president of the Morehouse School of Medicine in Atlanta, one of the top African-American medical schools in the country He is also one of the leading diabetes researchers in the United States and chairman of the National Diabetes Education Program As a scientist, Dr Gavin has a deep interest in insulin Insulin is a hormone that strongly influences blood sugar levels As doctor and medical school president, he has his
sights set on people and what can be done to keep them from getting diabetes Dr Gavin says the root of the problem is the rise of unhealthy eating habits and the decline of physical activity as part of everyday life Even kids dont walk, run, or ride bicycles as much as they used to We have to recognize the price were paying for worshipping at the god of convenience, he says Dr Gavin grew up in Mobile, Alabama, when there were segregation laws denying African Americans equal rights Even so, his father worked his way up to become head of the department in charge of the paints and other coatings at a large shipbuilding company The job involved a lot of practical chemistry He was so much smarter than me, Dr Gavin says of his father I have no doubt he would have been a great scientist if there had been more opportunities for African Americans Dr Gavin earned a PhD in biochemistry from Emory University in Atlanta and then his medical degree from Duke University in North Carolina
Gavin, continued on next page

Diabetes: The Science Inside
He sounds a little like a space explorer in the movies when he explains why he became a scientist You are facing this vast universe of the unknown
All knowledge comes from scientists having a question and exploring a small part of the unknown through research Dr Gavins research was among the first to show that insulin interacts with blood cells Now scientists know that insulin roams all over the body, affecting many cells and organs Blood sugar has many effects, too So now doctors treat many people with diabetes with several drugs at once Therapy with a single drug just doesnt cut it for most patients, says Dr Gavin The diabetes rate in African Americans has tripled in the past 30 years Dr Gavin says that African Americans may have genes that make them more vulnerable to the disease But genes are only part of the story Only changes in diet and exercise could explain such a fast increase over a relatively short period of time Dr Gavin says there is now a program that encourages friendly competition among groups of African-American men to see which group can become more active and lose weight We need to put a greater emphasis on prevention, he says One way to do that is to get groups in the community working together to reach a common goal

Part 2: Who has type 2 diabetes?
Rising incidence of type 2 diabetes
In the last half
century there has been a steady rise in type 2 diabetes Diabetes is now on the list of top ten diseases affecting Americans Researchers give several reasons for this increase One reason is that the health care system is getting better at diagnosing diabetes Cases that at one time might have gone unnoticed are now recognized A second reason is that the population is getting older, and aging is a well known risk factor for type 2 diabetes The third reason for the increase in diabetes is the most important Americans are eating too much for the amount of exercise they get As a result, many Americans carry too many pounds Health researchers say that 65 percent of adults in the US are overweight or obese — thats almost two-thirds of the adult population Rates of overweight and obesity are climbing for children and teens, too The rate is 16 percent for children ages 12 to 19, and 15 percent for children ages 6 to 11 Even the very young are gaining too much weight, with 10 percent of youngsters ages 2 to 5 falling into the overweight category Being overweight and obese are key risk factors for type 2 diabetes People who carry their extra pounds around the middle are at special risk The
risk comes even with just a few pounds of extra fat A recent study found that people who are in a high healthy weight range have up to twice the risk of diabetes as those in a low healthy range

Uneven impact of diabetes
For the US as a whole, diabetes affects women more than men Among Americans age 20 or older, 83 percent of all men have diabetes, compared to 89 percent of all women Diabetes strikes unevenly in other ways, too

According to the Centers for Disease Control, the percent of obese adult American women rose from 122 in 1991 to 208 in 2001 Over this same 10-year period, the percentage of obese Hispanic women rose from 116 to 237 and the percentage of obese Black, nonHispanic women rose from 193 to 311 Obesity is associated with a variety of illnesses, including diabetes and high blood pressure

Diabetes: The Science Inside Do you weigh too much?
Are you carrying around too much fat? The answer to that question is important, because extra weight puts you at extra risk for type 2 diabetes According to the National Heart, Lung, and Blood Institute guidelines, assessment of overweight involves using three key measures: body mass index BMI waist circumference, and
risk factors for diseases and conditions associated with obesity The BMI is a measure of your weight relative to your height and waist circumference measures abdominal fat Combining these with information about your additional risk factors can tell you about your risk for developing obesityassociated diseases, such as diabetes There is a web site that calculates BMI for adults and children using English units pounds and inches or Metric units meters and kilograms Go to BMI: Body Mass Index, Centers for Disease Control, http://wwwcdcgov/nccdphp/ dnpa/bmi/ Talk to your doctor to see if you are at an increased risk and if you should lose weight Your doctor will evaluate your BMI, waist measurement, and other risk factors People who are overweight or obese have a greater chance of developing type 2 diabetes, and even a small weight loss just 10 percent of your current weight will help to lower your risk of developing this disease

Type 2 affects a far higher proportion of people from minority ethnic and racial groups than it does white Americans Some groups have rates of type 2 diabetes that are two to three times higher than the rate for white Americans The populations at higher risk
for diabetes include African Americans, Hispanic Americans, Native Americans, Alaska Natives, Asian Americans, and Pacific Islanders Elderly people and poor people also are at increased risk

or more likely, a set of genes evolved in ancient people to help them survive periods of famine The gene helped their bodies store the most energy possible from food, for later when food was scarce Today, people who inherit the thrifty gene usually do not face long periods with little food All the same, their bodies are quick to build up fat, leading to higher risk for type 2 diabetes Theres another side to this thrifty gene theory Some ancient people travelled over great distances and used huge amounts of energy tracking down food The ones who survived had genes that could support this high-activity lifestyle They passed down those genes to their children Most people today with these genes are far less active, and this again could lead to easy weight gain and type 2 diabetes

Genetic reasons for the uneven impact
Health researchers are trying to explain why diabetes has such an unequal impact on minority groups This unequal impact is called a health disparity Several theories try to explain
the diabetes health disparity One set of theories has to do with genetics This is the field of science that looks at how genes are passed down through families to affect traits For example, it is thought that some racial or ethnic groups carry genes that increase the chances of developing diabetes This is referred to as genetic predisposition One theory along this line is called the thrifty gene theory According to this theory, a gene

The uneven availability of health care
There is another reason for the diabetes health disparity It is that health care is more available to some people than to others Those people who have good health care are more likely to have their type 2 diabetes diagnosed early, treated, and kept under control They have a better chance of avoiding type 2

Part 2: Who has type 2 diabetes?
diabetes in the first place because they receive medical advice on how to stay healthy Most people in the US receive health insurance through their jobs People without jobs, or with lowwage, part-time or temporary jobs, may not have health coverage for themselves or their families People who move around frequently, such as migrant workers, also may have more limited access
to health care Wealthier people are more likely to have better coverage from their health insurance Plus, they can afford to pay for extra medical costs that might not be covered by insurance They are more likely to be served by doctors who have the latest equipment and knowledge All these factors can lead to big differences in the amount and quality of care received Consider the fact that a certain type of diabetes treatment costs about twice as much as other forms of diabetes care This is because it requires more check-ups and more supplies for blood testing see page 33 for information on this form of treatment, which is called tight control Over the long run, this treatment leads to better health Those who cannot afford it have less fortunate outcomes

Other factors leading to the health disparity
Poor people have a harder time taking care of their health, and this is not just because they have less access to good health care They are less likely to live near a large grocery store stocked with good produce and other fresh food ingredients As a result they may tend to eat a greater proportion of prepackaged, processed foods that contain more fat, salt, and sugar In some poor
communities, the water supply is not very good so people tend to drink more bottled or canned beverages such as soft drinks People who are poor may not live near good recreation centers or be able to afford the fees Some people also do not have the education they need to take care of their own health They may not have learned how to read food labels to avoid high-salt, high-sugar, and high-fat foods They may not

For Hispanic Americans 50 years or older, up to 30 percent are diagnosed with diabetes or have the disease but dont know it

Diabetes: The Science Inside
know how to fit fruits and vegetables into their budget They may not know about the low-cost, easy ways to fit exercise into everyday life They may not value fitness because they do not know how it connects to health Such people are less likely to develop healthful eating and exercise habits All of these factors can lead to overweight or obesity, conditions linked to type 2 diabetes In these kinds of ways poverty, which affects minority groups in greater proportion than it does whites, can create a diabetes health disparity Until recently, most diabetes education efforts have been aimed at the white, English-speaking,
middleclass, native-born American These efforts have been less effective at educating other types of people For example, many immigrants to this country do not speak English well Many immigrants as well as nativeborn Americans do not read well or have very limited education Such people are not likely to understand the diabetes information that is available by talking with health care workers or from TV, radio, books, and information sheets Sometimes health information fails because it does not make sense to people based on how they look at the world For example, some immigrants have moved here from less-developed countries where death and disease are more common and health care is hard to come by In their home country, they may have had very little control over sickness These people may have learned to be passive in the face of an illness such as diabetes In fact many groups of Americans, not just some immigrants, share this acceptance of fate They do not think of a disease like diabetes as something to prevent or manage

Diabetes affects all types of people
In the total US population, 17 million people have diabetes Thats more than 6 out of every 100 people Each year,
about 1 million new cases are diagnosed in adults age 20 years or older Among children and teens people under age 20, more than 150,000 have diabetes — about 1 in every 500 Among people age 65 and over, 7 million have diabetes — about 20 out of every 100 Among Non-Hispanic whites, about 114 million have diabetes — almost 8 out of every 100 Among Non-Hispanic blacks, 28 million have diabetes — about 13 out of every 100 Among Hispanic/Latino Americans, 2 million have diabetes — more than 10 of every 100 Among American Indians and Alaska Natives, 105,000 have diabetes — more than 15 of every 100 — but this number only includes those who receive care from the Indian Health Service The number for the entire group is certainly higher For Asian Americans, Native Hawaiian, or other Pacific Islanders, the total number with diabetes is unknown Studies on individual groups within this population show them to be at higher risk for the disease, compared to non-Hispanic whites

Part 2: Who has type 2 diabetes?
For some people, tradition tells them to be respectful or even fearful of doctors They may have a hard time seeking help from doctors, asking them questions, or accepting the
idea of being a partner with doctors in their own care Teenagers come from a different culture than adults Young people are not used to thinking about sickness and death They do not easily connect todays actions to tomorrows health They also are more concerned with growing up and fitting in These concerns can make it much harder for teens to follow diabetes prevention or treatment advice Diabetes has earned yet another nickname — the wasteful disease Its called that because so much illness and death can be avoided It can be avoided if everyone receives proper health care, if everyone is reached with health information, and if everyone at risk from diabetes takes action for their health Because of economic, cultural, and lifestyle barriers, this is not happening Until it does, diabetes will have an unequal impact across America

Raul Sosa
What was Raul Sosas attitude toward diabetes? Didnt have it, he says Didnt care Now he cares–a lot Sosa was diagnosed with type 2 diabetes eight years ago He has lost weight, quit smoking, and gets exercise He is also careful about what he eats Sosa says he is motivated partly by the example of his father His father didnt have diabetes But he had
a heart attack when he was about 40 Diabetes makes people vulnerable to heart attacks His heart condition dominated the rest of his life after his heart attack, Sosa says I really didnt want that to happen to me
Sosa, continued on next page

Diabetes: The Science Inside
Diabetes runs in Sosas family His mother, Aida, and several of her sisters have the disease The Sosas arent alone Many Latino families are affected by the disease On average, Latino Americans are about twice as likely to have diabetes as other people of the same age About 10 of Latino Americans have diabetes Sosa lives in Evanston, Illinois, outside of Chicago and works as a computer technician for an insurance company He is 5-foot-8-inches tall and weighed about 240 pounds when he was diagnosed with diabetes Sosa got some exercise, but nothing that would burn a lot of calories He pitched for several softball teams and played golf, although he admits I rode in a golf cart most of the time And his eating habits were, well, pretty bad His weakness? Breyers vanilla ice cream I used to sit and eat a half gallon at a time, says Sosa That is how I got to 240 pounds Sosa was diagnosed with diabetes after his
periodonist a dentist who takes care of gums thought his bad gums might be from diabetes Blood tests showed the periodonist was right Sosas doctor was blunt: He said, Mr Sosa if you dont do what I tell you to do, youre going to die Most doctors arent going to scare their patients like that, but the harsh warning got Sosas attention I dont want diabetes to be the most important thing in my life, he says At the same time, I know I need to take care of myself Sosas blood sugar is under control, partly because he takes diabetes medications But he has also lost a great deal of weight He now weighs 170 pounds, 70 less than he used to He goes to the gym nearly every day and competes in bicycle races during the warm-weather months Food is a challenge Chicken, vegetables, and whole grains are on his menu He tries to steer clear of restaurants that specialize in large portions And he has put a total ban on ice cream I like it too much to just eat in moderation

Part 3: How is type 2 diabetes prevented and treated?
Diagnosing diabetes
Although the amount of glucose in your blood varies depending on when and what you eat, the range should be relatively narrow In general, your blood sugar
is highest after you eat and lowest after you have not eaten for 8-10 hours After fasting all night, most persons have blood glucose levels between 70 and 110 milligrams of glucose per deciliter of blood mg/dL After eating a large meal, a persons blood sugar will rise, but generally not above 140 mg/dL People with untreated diabetes will have higher blood sugars after fasting and after eating To check if you have diabetes, your doctor will test your blood sugar levels The results of these tests and other clinical findings will be used to decide if you have diabetes and what type Doctors cannot diagnose diabetes on the basis of one single test Instead, they will perform two or more glucose tests before confirming your diagnosis The most common tests to measure glucose are the fasting plasma glucose test, the random blood sugar test, and the oral glucose tolerance test

Fasting plasma glucose test Most experts recommend using a fasting plasma glucose test to diagnose diabetes Before taking this test, you cannot eat anything for 8 to 10 hours Blood will be drawn from a vein in your arm and sent to a laboratory for testing If your fasting blood glucose is 126 mg/dL or higher, your
doctor will probably diagnose you with diabetes Random blood sugar test Many cases of diabetes are found during routine physical exams when blood is drawn for other tests Since you dont necessarily fast before these physical exams, you may have just eaten and your blood sugar may be high Even so, it shouldnt be higher than 200 mg/dL If your random blood glucose is higher than 200 mg/dL, your doctor will probably suspect diabetes and may want to give you a fasting plasma glucose test Oral glucose tolerance test In this test, a person consumes a drink containing glucose dissolved in water Blood is then drawn in timed intervals over a three-hour period If plasma glucose levels rise more than

Diabetes: The Science Inside Diabetes touches some groups more than others
For all age groups, white Americans are less affected by diabetes compared with Americans from other racial and ethnic groups American Indians and Alaska Natives are 26 times as likely to have diabetes as non-Hispanic whites of a similar age Rates vary widely among tribes, on average African Americans are 2 times as likely to have diabetes as white Americans of similar age, on average Hispanic Americans are 19
times more likely to have diabetes than non-Hispanic whites of similar age, on average Mexican American and Puerto Rican adults are at slightly greater risk and Cuban Americans at slightly lower risk Some Asian American and Pacific Islander groups may at increased risk for diabetes compared with non-Hispanic whites For example, studies conducted among Native Hawaiians indicate that they may have much higher rates of diabetes than non-Native white residents of Hawaii Most children with type 2 diabetes are minorities

Doctors will diagnose type 1 or type 2 after studying the patients symptoms and medical condition People diagnosed with type 2 diabetes tend to have less severe symptoms In fact, some people with type 2 do not realize they have the disease until they are given their glucose test results People with type 2 tend to be overweight, even though unexplained weight loss may be one of their symptoms People with type 2 also may show signs of the complications of diabetes, such as nerve pain or eye problems This is because they may have had the disease for years without knowing it Sometimes a test will reveal that your glucose level is higher than normal, but not high enough to
fit a diagnosis of diabetes Instead you may be told that you have prediabetes This means you have a high risk of developing type 2 diabetes or suffering from diabetes-like problems

and it hits them harder, too
As groups, many ethnic and racial minorities have less risk for cardiovascular disease than white Americans However, this protection ends for those who develop diabetes In these groups, cardiovascular disease is the main cause of death linked to diabetes Minorities with diabetes are more likely to have more lower limb amputations Diabetes-related kidney failure occurs at higher than average rates for African Americans, Native Americans, and Hispanic Americans Gestational diabetes affects just under 5 percent of all pregnancies But for minorities, the rate is almost 15 percent Among African-American women, the rate of gestational diabetes is more than double the rate for white women

Preventing and controlling diabetes
There is not yet a cure for type 2 diabetes It is a chronic disease, which means it is long-lasting and on-going A patient who is diagnosed with the illness has it for life Fortunately, it can be controlled through treatment In fact, the symptoms may
practically disappear so long as treatment is followed

expected, the person is diagnosed with diabetes This test is often used to check pregnant women for gestational diabetes It is rarely used to diagnose diabetes in other patients, because it is cumbersome and time-consuming

Part 3: How is type 2 diabetes prevented and treated?
Its important to diagnose type 2 diabetes as early as possible, so that treatment can be started and complications avoided Your particular treatment will be tailored to your state of health, your particular body, your personality, and your lifestyle Your treatment also may change over time, so you need to have an on-going relationship with health care providers There are four main tasks in the treatment of type 2 diabetes: Less than half of all people with type 2 diabetes must take insulin The rest produce enough insulin so that they do not need to take it by injection Instead they may manage their blood sugar by taking pills These pills increase the effect of the insulin already in their bodies or block the uptake of glucose from the gut Because many people who have type 2 diabetes do not need to take insulin to survive, this form of the illness has
sometimes been referred to as noninsulin-dependent diabetes This contrasts with insulin-dependent diabetes, which is another term for type 1 diabetes Over time type 2 patients may lose the ability to produce enough insulin When this happens, they must start injections Many women with gestational diabetes can get by without taking insulin, but some have to take insulin or take pills Some people take insulin at set times in the day, such as morning and evening Others take insulin as needed based on readings of their blood sugar You measure blood sugar using a blood glucose meter You draw a drop of blood and put it on a strip of plastic that you insert into the meter Some meters use chemicals and others use electricity to measure the glucose If you have diabetes, you may have to test your blood sugar and take insulin many times a day regardless of the treatment you are on

Eat healthfully and get exercise Manage your blood sugar Keep your blood pressure under control Keep your cholesterol levels in the healthy range

If you have type 2 diabetes, it will be your job to carry out these tasks Your health care providers will give you advice, medical care, and drug prescriptions as
needed However, the most important person in managing your day-to-day care will be yourself

Managing blood sugar
If your body fails to make insulin, then insulin has to be added to keep it healthy You do this by injecting insulin — either with needle shots, high-speed jet injectors, or pumps attached by a thin tube to the body

Diabetes: The Science Inside

Its important to test your blood sugar often because many factors can affect your levels For example, eating certain foods can cause blood sugar to rise Exercise can cause blood sugar to drop because active muscle cells use up their glucose and pull more out of the bloodstream Stress and illness both may trigger the release of extra hormones that send blood sugar to higher levels Therefore a person with diabetes may test before, during, or after eating, exercising, experiencing stress, or suffering an illness If the blood sugar is high, they may take extra insulin If the blood sugar is low, they may eat a little more carbohydrate food or take a glucose tablet These tablets are an easy-tocarry way to put glucose into the blood stream more quickly and conveniently than food

Eating healthfully
Many cases of type 2 diabetes
can be controlled almost completely by eating healthfully A good diet can help keep blood sugar levels stable, bring blood pressure down, and keep cholesterol at healthy levels As a result, by eating healthfully you may be able to avoid the need for diabetes pills or insulin injections You also stand a better chance of avoiding the complications of diabetes There are several different eating plans for people with type 2 diabetes If you have the disease, the plan that

Tests are used to monitor blood pressure and cholesterol
If you have diabetes, your blood pressure should be below 130/85 mm Hg If either number is higher, you may need to be treated for high blood pressure If you have diabetes, your LDL bad cholesterol should be less than 100 mg/dL Your HDL good cholesterol should be at least 40 mg/dL men or 50 mg/dL women Your triglycerides a bad fat should be under 150 mg/dL If your numbers differ from these guidelines, you may need to be treated for cholesterol

Part 3: How is type 2 diabetes prevented and treated?
is best for you will depend on the state of your health, your reactions to certain foods, your tastes, and your lifestyle Most eating plans include these
recommendations:

Avoid high-cholesterol foods These are foods from animal products such as meats, butter, cheese, whole milk, cream, and eggs Watch portion size Portions that are too large may cause you to gain weight and may drive up your blood sugar One way to watch portion size is to measure your food Another way is to use the plate method to keep your portions in balance see pg 20 Do not drink large amounts of alcohol Blood sugar drops as alcohol is digested Too much alcohol can lead to hypoglycemia, which in turn can cause dizziness and confusion These are the same symptoms as for being drunk A person who has had some drinks may not be alert enough to recognize that they are not just tipsy but also hypoglycemic This can be very dangerous because hypoglycemia must be treated right away Also, heavy drinking can lead to nerve damage over time This is on top of the nerve damage that can come from diabetes Finally, overconsumption of alcohol can lead to bad cholesterol levels, which worsens the risks for heart disease

A variety of insulin products are now available
Insulin is dissolved in a liquid The standard strength is U-100, which means there are 100 units of insulin per
milliliter of liquid Most of the insulin used for diabetes today is grown in the laboratory In earlier times insulin was extracted from the pancreas of cows and pigs This is less common today, because it is a more difficult process and some people are allergic to animal insulin Some types of insulin reach the blood very quickly to begin lowering blood sugar Others are slower to take effect but last longer This characteristic of insulin is known as action time Insulin products with different action times can be used together If you need to take insulin, your health care team will help you find the insulin products that work best for your body and your lifestyle

Watch the carbohydrates sugars and starches you eat The best carbohydrates for the diabetic person contain fiber, are not heavily processed, and are not too sugary Good choices include apples, peas, beans, whole grain rice, whole grain breads, and oat or bran cereals For cooking and seasoning, use vegetable oils such as olive, canola, corn, and peanut oil instead of animal fats such as lard, bacon grease, side meat, or fat back Also, use herbs and spices instead of salt Avoid foods that are high in saturated fat fat from
animal products and hydrogenated fat vegetable oils that have been processed into solid fats Saturated fat is found in fatty meats, processed meats, cheese, whole milk, ice cream, butter, and lard Hydrogenated fat is found in hard stick margarine and shortening and in many processed foods, snack foods, and fried foods Check the labels of packaged snacks and sweets Avoid the ones that contain coconut oil, palm oil, or hydrogenated vegetable oil

If you want to drink alcohol occasionally, consult with your health care provider about the amount that is safe for you

Diabetes: The Science Inside Getting exercise
Exercise is a key part of treatment for type 2 diabetes, because it uses up glucose and therefore lowers blood sugar At the same time, it reduces insulin resistance, which also lowers blood sugar One concern about exercise, however, is that in some circumstances hard physical activity can cause blood sugar to drop too low This is especially true for people who are taking glucoselowering drugs Therefore, anyone with type 2 diabetes needs to have an exercise plan, to make sure the workout is the right amount at the right level Walking is often recommended because it
is easy on the body, free, enjoyable, requires no equipment, and can be done almost anywhere Another benefit from exercise is that it lowers cholesterol This reduces your risk for the heart disease that is associated with diabetes It also lowers blood pressure, which reduces your risk for both strokes and heart problems Finally, regular exercise can help you be fit and trim This is an important benefit since overweight and obesity are key risk factors for type 2 diabetes and its complications

Monitoring your blood pressure
Blood pressure is the force of the heart as it pushes blood through the arteries, the blood vessels that carry blood away from the heart Measurement of blood pressure is easily done by a health care provider using a cuff placed on your arm Blood pressure is measured at two different moments:

The plate method is an easy way to control food portions
Just set aside half the plate for salad and vegetables Use about a quarter of the plate for protein foods and the rest for carbohydrates Ask your health care providers for more tips on meal planning You can also ask at the library for cookbooks and meal planning guides geared to the person with type 2 diabetes

When
the heart beats This is systolic pressure, and it is when blood pressure is highest When the heart rests between beats This is diastolic pressure, and it is when blood pressure is lowest

Both measurements are important If either one is too high, it is a sign of high blood pressure Your blood pressure varies during the day, depending on what you have been doing and your emotions Therefore, health care providers like to determine your average blood pressure by measuring it over time such as at several doctors visits High blood pressure must be treated to prevent strokes, heart attacks, vision problems, and other complications of diabetes Treatment for high blood pressure may include improvements

Part 3: How is type 2 diabetes prevented and treated?
to your diet such as eating less salt, changes to your lifestyle such as more exercise, and medicines follow in order to maintain good health Ideally, this treatment plan is put together by a team of health professionals working with the patient If you have type 2 diabetes, an important part of your plan will be regular visits to health care providers Your symptoms will be reviewed at each check-up You may undergo a special blood
test to find out how glucose levels have averaged over the past few months Medicines may be prescribed to control blood sugar, blood pressure, or cholesterol You will meet with specialists to check various parts of the body such as the eyes, feet, and teeth You also may see mental health professionals for help dealing with the challenges of the disease Between visits with health care providers, treatment rests in your hands In diabetes health care this is called self-management, and it is central to the success of any plan The reason it is so important is that a treatment plan is only good if it is followed If you have diabetes, selfmanagement training can help you gain the skills and confidence needed to succeed with a treatment plan In self-management training you learn how to monitor blood sugar, how to take injections, how to pay attention to your bodys signals and symptoms, and how to take special

Pills may be prescribed for type 2 diabetes
If you have type 2 diabetes, you may get prescriptions for one or more diabetes pills Heres what they do: Oral hypoglycemics work on the pancreas to increase insulin production Starch blockers slow digestion so that glucose does not rise
too quickly after eating Metformin slows down glucose production in the liver and speeds glucose uptake by the cells Insulin sensitizers make body cells more receptive to insulin

Keeping cholesterol at healthy levels
Cholesterol is checked by drawing blood The blood test measures the presence in the blood of two different types of cholesterol HDL and LDL and triglycerides The healthy range for each measurement varies depending on the number of risk factors for heart disease that you have examples of these risk factors include high blood pressure, having family members with heart disease, advanced age, and being a smoker People with diabetes are at twice the risk for cardiovascular disease If any measurement is outside the healthy range, you may need to be treated to prevent heart disease Treatment for high-risk cholesterol levels may include improvements to your diet such as eating more fiber and less fatty foods, changes to your lifestyle such as more exercise, and medicines

Diabetes treatment plans
Eating healthily, getting exercise, and monitoring blood sugar, blood pressure and cholesterol, are the cornerstones to controlling diabetes These tasks often go together in a
treatment plan The plan is a set of steps for a person with diabetes to

Diabetes: The Science Inside
care of the skin, feet, and teeth You get advice on how to shop for and cook healthful meals and how to select the right foods off a menu You learn the best way to exercise and how often to do the workout Finally, you learn how to keep a daily log of blood sugar levels, meals, exercise, and symptoms The log is referred to at check-ups and it is used to fine-tune the treatment plan

You should be tested for diabetes if you have symptoms or are at risk
You should be tested for diabetes if you have the symptoms described on page 4 You should be tested every three years if you have no symptoms but are over age 45 And if you have one or more risk factors see below, you may want be tested more often and starting at an earlier age You should be tested if you are an overweight child or teen with two or more risk factors see below

Pumps offer convenience and good control
If you have diabetes and want to maintain tight control, discuss the benefits of using a pump with your health care team A pump is a small device, about the size of a pack of cards, that you wear or carry Insulin moves
from the pump to your body through a thin tube to a needle that is inserted under your skin You can program the pump to automatically deliver doses of insulin You can also control the pump to give extra insulin, or to adjust amounts, based on your blood sugar tests Pumps have several benefits You dont have to stick yourself with a needle every time you need insulin, because the pumps needle stays painlessly in place for days at a time You dont have to remember when to give yourself regular doses of insulin because the pump remembers for you And if you eat a little extra sugar, work out a little harder than usual, or in any other way cause your blood sugar to go up or down, you can easily adjust the pump

Risk factors:
Close relative with diabetes Belonging to an at-risk group Native American, Alaska Native, African American, Hispanic American, Asian American High cholesterol High blood pressure History of impaired glucose tolerance Dark and thickened patches of skin, usually on the neck, under the arms, or inside the elbows this symptom tends to appear in obese members of ethnic minority groups These patches are called acanthosis nigricans Having diabetes when pregnant OR
delivery of a baby that weighs more than nine pounds

Part 3: How is type 2 diabetes prevented and treated?

Dr Francine Kaufman
Life for children with diabetes is complicated They must be careful about keeping their blood sugar levels just right–and be kids It is a continual balancing act of the medications, the amount of insulin you take, your activity, and what you eat, says Dr Francine Kaufman For over 25 years, Dr Kaufman has been helping children with diabetes and their families keep that balance She is director of the Comprehensive Childhood Diabetes Center at Childrens Hospital Los Angeles She is also president of the American Diabetes Association, the largest organization in the country for doctors who treat people with the disease Dr Kaufman says she specialized in diabetes care for children because she wanted to build relationships over many years She is especially close to several patients Lance Kinkead and Lupe Pena are two patients who have moved in and lived with Dr Kaufmans family Karen Matsuoka is a former patient who says Dr Kaufman instilled with her life-long self-confidence See adjoining article Ideas about how best to care for children with
diabetes have changed since Dr Kaufman entered the field Doctors worried that trying to keep blood sugar under control might be dangerous They feared that control would go too far and sometimes cause sudden dips in sugar levels that could cause comas and other problems Doctors also figured that the complications from high blood sugar did not come until later–after children had grown up and become adults But studies showed that tight sugar control is important to preventing complications from diabetes, even in children Researchers also proved that tight control can be accomplished without producing sugar lows In addition, invention of home glucose monitoring devices has made it relatively easy for children and their parents to check blood sugar levels several times each day Glucose is another word for the type of sugar in the blood
Kaufman, continued on next page

Diabetes: The Science Inside
Now children and their families are involved in the medical care of diabetes on a daily basis We are asking them to do several diabetes-related tasks every day, says Dr Kaufman Dr Kaufman and the American Diabetes Association are now working with educators to make sure diabetic children
get help during the school day Dr Kaufman says, It really comes down to protecting the rights of these children to go to school like everyone else In some ways, machines are making it easier for even children to take care of diabetes Prickless devices collect blood samples for glucose monitoring Instead of insulin injections, many people have automatic pumps that provide a continuous flow of insulin through a plastic tube inserted just under the skin In the future there may be something like an artificial pancreas It will read blood sugar levels and provide insulin whenever it is needed But machines cant replace doctors like Dr Kaufman Diabetes is a complex, lifelong condition, she says The doctor, the patients, and their families really need to be partners, working together

KAREN MATSUOKA
I couldnt have asked for a better doctor, says Karen Matsuoka, a 28-year-old Stanford graduate and Rhodes Scholar who has been a patient of Dr Kaufmans since she was a young girl Matsuoka first met Dr Kaufman at a camp for diabetic children On the first day of camp I was waiting in line for dinner when I started to cry for no particular reason Dr Kaufman was busy giving other children their
evening injections but she immediately dropped everything, took me aside, held me on her lap, and asked me what was wrong Sure enough, my blood sugar was low I knew she was very busy and had hundreds of other kids to look after, but she made me feel that she had all the time in the world for me if I needed it Some doctors are like drill sergeants, says Matsuoka They tell their patients what they can and cannot do Not Dr Kaufman, she says: Her philosophy was more Okay, you want to do something Lets figure out a way for you to do it while keeping your blood sugars in the normal range Dr Kaufman helped me realize that diabetes is only as limiting as I allow it to be I think this is the greatest gift that any physician can give to their patients with a manageable chronic illness like diabetes When Matsuoka has finished her studies, she wants to be a health care policy analyst and work on improving access to health care Yes, to a certain extent, how well diabetic patients do is up to them and how well they control their diabetes But if they cant even afford blood-testing supplies, how can anyone expect them to stay well?

Part 4: How do researchers study diabetes?
Discoveries
through research
Long ago, insects were used to diagnose diabetes A doctor would pour a patients urine next to an anthill If the ants ran over to the urine, then it contained a lot of sugar and this meant diabetes It was simple, but it was scientific Over the centuries, other discoveries followed In the 1700s, scientists figured out that sugar is not just in the urine of people with diabetes Some amount is in everyones body fluids This led to research into the purpose of blood sugar About one hundred years later, researchers learned about the role of the pancreas It started when a researcher experimented on a dog After he removed the dogs pancreas, the dog urinated a great deal The researcher knew this was one of the symptoms of diabetes This discovery led to a search for what happens inside the pancreas to cause diabetes After several decades of work, researchers learned that certain cells produce insulin These cells are found in the pancreas Because they lie in island-like clumps, they are called islet cells It was many researchers working over many years who discovered the benefits of injecting insulin, who figured out how to extract and purify insulin from animals, and who
invented the technique for growing human insulin in the laboratory And it was many researchers working over

Researchers work on new products that make it easier to manage diabetes
For many people with diabetes, treatment is a lot of trouble Thats why a great deal of research goes into finding products that can make treatment tasks easier Here are some products that may soon be available: An internal insulin pump An internal pump will not be as cumbersome as the kind worn outside the body, and it will not use any needle The internal pump will automatically sense blood sugar and deliver the needed amount of insulin Insulin inhalers Instead of injecting insulin, a person will simply hold the inhaler to the mouth and breathe in a spray Inhalers have been around a long time, but until now they have not been effective with insulin That problem appears to be solved with these new inhaler models Other insulin-delivering products in the research stage include skin patches, nasal sprays, and pills Currently insulin is not available in pill form because when pills reach the stomach, the insulin is destroyed during digestion Glucose watches These watches do not tell time Instead they use tiny
electrical impulses to measure blood sugar in the blood vessels of the wrist They set off an alarm when blood sugar falls outside a programmed safe range They also keep records that can be transmitted to a computer and printed out, so patients do not have to keep written logs Other glucose-monitoring devices under development include sensors that are implanted under the skin, handheld lasers, and ultrasound devices

Diabetes: The Science Inside
many years who discovered how to diagnose diabetes, how to treat it, and how to reduce the complications This research has led to big improvements in the quality of life for people with diabetes It also lends hope to the promise of someday finding a cure nosis, prevention, and treatment strategies Just one example of how this partnership has worked is a study comparing the Arizona tribe to another Pima tribe in Mexico The Mexican Pimas live traditionally They eat more healthful foods and lead more active lives They also have a much lower rate of diabetes This research helped confirm the connection between lifestyle and diabetes Genetic research Researchers are investigating the genes that regulate body weight, energy use, and body type
They are figuring out how these genes affect the development of obesity and diabetes in different groups They are exploring ways to alter gene function to prevent the weight gain that can trigger diabetes, how to prevent the disease itself, and how to reduce its complications Some of this research takes place in the lab, using gene samples and high-tech equipment Researchers look inside cells to see how genes send signals to trigger activity in the body They hope to figure out how to correct the improper signalling that leads to diabetes Other gene studies take place in the field Researchers talk with families to learn about how the disease has passed down through the generations and the particular ways it has affected them

Current lines of research
Research continues to explore more questions about diabetes Why does it affect some groups more than others? How can treatment be made better and easier? How can diabetes be prevented? What are the best ways to educate people about diabetes? Today, research in all branches of science is adding to the knowledge about diabetes Here are some of the types of research underway Population studies By studying a group of people over time,
researchers can learn a great deal about how they are affected by a disease One of the most significant population studies in the diabetes field has focused on the Pima Indians of Arizona More than 30 years ago, researchers noticed that the Pimas had a very high rate of diabetes The Pimas agreed to volunteer for diabetes research, and the partnership continues to this day This research has yielded valuable information about the nature of the disease and its effects on the body Information from the research has helped with diag-

Part 4: How do researchers study diabetes?

Uncontrolled diabetes can lead to serious health problems
When type 2 diabetes is undiagnosed or not controlled properly, it can lead over time to major damage to the body The many problems linked to diabetes are described below Its important to remember that these problems often can be avoided or delayed if the diabetes is controlled Be sure to read on to the next chapter, How is type 2 diabetes prevented and treated? DIABETIC ACIDOSIS Glucose builds up in the blood when the body does not have enough insulin to move it inside cells needing nourishment This condition is called hyperglycemia Despite all the
glucose, the body acts as if none is available It begins to breaks down muscle and fat cells in search of glucose The fat is converted to strong acids called ketones In large amounts, ketones in the blood are like poison and can lead to shock, difficulty breathing, and coma INSULIN REACTION If there is too little glucose in the blood, a condition called hypoglycemia can occur This causes weakness, tiredness, confusion, dizziness, sudden sweating, rapid heartbeat, strange behavior, and passing out A sudden onset of these symptoms is called an insulin reaction All persons with diabetes have to guard against insulin reaction However, it occurs more often in people who inject insulin to control their diabetes The symptoms can be reversed by eating or drinking a product containing sugar or by taking glucose tablets NERVOUS SYSTEM DISEASE Diabetes leads to nerve damage, called neuropathy This can cause loss of feeling and pain, especially in the feet or hands It also can cause problems in the heart, digestive system, sexual organs, and just about every other part of the body Problems may take years to develop, but up to 70 percent of people with diabetes suffer from some type of nervous
system damage CARDIOVASCULAR DISEASE The nerve damage from diabetes can have an effect on heart rate Diabetes also affects the bodys cholesterol levels Two proteins called lipoproteins carry cholesterol to and from cells Many people with diabetes have too much of the lipoprotein that delivers cholesterol to cells this is called LDL As a result, cholesterol tends to clog and scar blood vessels This makes it more difficult for blood to pass through People with diabetes also are at risk for high triglycerides, a form of fat that the body obtains from food and uses for energy Along with cholesterol, trigycerides can clog and scar blood vessels Together, these complications from diabetes can build up to cardiovascular disease Symptoms range from weakness and poor circulation to heart attack and stroke The rate of cardiovascular disease among people with diabetes is two to four times as high as it is for adults without the disease It is the number one cause of diabetes-related deaths BLINDNESS The damage from diabetes to nerves and blood vessels can destroy the retina, a light-sensing part of the eye This problem is called retinopathy, and it can lead to blindness People with diabetes
have a 25-times greater risk for blindness compared to the general population KIDNEY DISEASE Diabetes stresses the kidneys and reduces their function This kidney damage is called nephropathy Damaged kidneys no longer clean the blood properly Waste builds up in the bloodstream, leading to grave sickness Survival may require a kidney transplant or dialysis, the use of a machine to clean the blood Diabetes is the most common cause of kidney failure AMPUTATIONS Because diabetes stresses the heart and blood vessels, blood does not travel through the body the way it should Poor circulation of blood reduces the amount of food and oxygen that are delivered to cells and the amount of waste that is carried away Poor circulation can be a particular problem for the feet, which are farthest from the heart Infected skin and sores to the legs and feet are more likely to occur and they may not heal properly These problems may not be treated promptly because they go unnoticed due to the loss of sensation from nerve damage If the decay is bad enough, the limb must be cut off More than 60 percent of all lower limb amputations in the US happen to people with diabetes GUM DISEASE: Because of the damage
to body tissue caused by diabetes, gum disease is a common side effect that can lead to tooth loss For people over age 19 with type 1 diabetes, about 30 percent have gum disease COMPLICATIONS OF PREGNANCY Babies born to mothers with diabetes are at risk for growing too large, too fast This can lead to an early delivery and the complications of being born before the lungs are ready If the baby is very large at birth, the delivery may be difficult The diabetic mother also is at higher risk for toxemia, an illness caused by the build-up of poisons in the bloodstream

Diabetes: The Science Inside
An example of this kind of research is a study taking place in five locations in Western Africa This research may uncover the reasons why diabetes hits so hard among African Americans Weight management Three great puzzles yet to be solved by science are: how to lose extra weight, how to keep it off, and how to stay slim in the first place A lot of current research seeks to solve these puzzles This would be a great advance against diabetes, since it mainly affects people who are overweight One example of this kind of study is trying to figure out how to help very young children lose weight
It involves children ages five to eight who are obese and have a family history that puts them at risk for diabetes and heart disease Another study of this type is focusing on prevention Called Quest, it is being conducted with the Pima Indians Children as young as kindergarten age are screened for diabetes, taught healthy habits, and provided with exercise and balanced meals at school A large US trial is looking at whether adult diabetes patients who get in shape have better health over the long term The study is nicknamed Look AHEAD, for Action for Health in Diabetes, and it will last more than ten years It involves 5,000 middle-aged, overweight men and women with type 2 diabetes Half the group is being put into a diet and exercise program with the goal of reducing weight by up to 10 percent in the first year The other half is being enrolled in education classes on nutrition and exercise Researchers also are trying to find out how various hormones help the body manage its supply of fat Researchers have discovered that they can make fat mice lose weight by giving them doses of different fatmanaging hormones They are trying to figure out how to make an artificial hormone product
that could help overweight humans lose weight Transplants Most kidney transplants are performed on patients with diabetes Some diabetes patients also have benefited from pancreas transplants A lot of effort has been spent in recent years to make transplants more successful Steady gains are being made in basic transplant techniques Researchers are learning how to overcome the problems of organ rejection, too These advances have opened the door for new attempts at islet cell transplants As explained earlier, islet cells are the cells inside the pancreas that produce insulin Recently in Canada a small trial of this type was successful in patients with type 2 diabetes This is very promising, because transplanting islet cells is a minor procedure compared to transplanting a

Part 4: How do researchers study diabetes?
whole pancreas The experiment is now being repeated in a trial involving volunteers from ten medical centers in the United States and Canada If this second trial shows positive results, then an even larger trial will follow Stem cell research Even if islet cell transplants become successful, they will not help everyone in need There simply are not enough donated
pancreata from which to extract islet cells Stem cells may present a way around this shortage Stem cells have the ability to grow into many different kinds of cells Researchers are trying convert stem cells into islet cells The labgrown islet cells could then be used for transplant Prediction Researchers are trying to learn how to better predict who is at risk for diabetes Researchers also are trying to learn how to predict who is at greater risk for the complications of diabetes Good prediction is important, because it could lead to more targeted prevention and treatment One idea researchers are looking at is to find the genes that are more common in people who develop diabetes If such genes are found, a gene test could be developed to predict those at risk Another idea is to study different groups of people to learn more about the unique ways in which they are affected by diabetes

These people will help you stay healthy with diabetes
Primary health care provider such as a doctor, nurse, or physicians assistant: monitors your overall health, directs medical treatment, and coordinates care Diabetes educator: teaches you how to follow the treatment plan and how to perform any
procedures that are part of the plan Dietician: matches you with an eating plan and provides training and support so you eat healthfully Exercise specialist: matches you with an exercise plan and provides training and support so you get the right physical activity Ophthamologist eye doctor or optometrist eye care professional: regularly checks your eyes to prevent and delay blindness Mental health professional: helps you maintain emotional well-being in the face of the changes brought about by diabetes Podiatrist foot doctor: regularly monitors your legs and feet to prevent problems and the need for amputation Dentist: regularly checks your teeth and mouth to prevent or treat gum disease Pharmacist: dispenses prescriptions, helps you keep track of medications, and offers advice on tools and equipment for managing diabetes

The important role of volunteers
Advances in diabetes knowledge could not happen without volunteers These are the people who agree to share information about their health, who agree to donate

Diabetes: The Science Inside
tissue samples for lab study, and who agree to participate in clinical trials Clinical trials are research projects, involving people who
have volunteered to participate They test the success of a medical treatment, medicine, or prevention strategy A clinical trial usually is conducted only after the treatment has been successful in laboratory tests and on animals Over the years, hundreds of thousands of Americans have volunteered to take part in clinical trials leading to todays better understanding of diabetes Diabetes affects different parts of the American population in very different ways For this reason, research into diabetes needs to involve Americans of all types — both males and females and people of all racial and ethnic groups, ages, and lifestyles In the past, researchers were not sensitive to the need to study different groups But today they are quite aware that research on one cluster of people may not reveal useful information about another group Many communities have begun to realize how they can benefit from taking part in research When a communitys members enroll in clinical trials, they stand a better chance of access to brand new, effective treatments At the very least, their health will be monitored by medical personnel during the course of the trial and they will have the best standard of care
These volunteers also get the satisfaction of helping uncover information that could some day reduce the impact of diabetes on their families and communities

Children and teens with type 2 present different challenges
The sharp rise in type 2 diabetes among teens and younger children creates all sorts of new challenges Many health care providers are not yet aware that this form of diabetes can affect children, and so they may not diagnose the illness properly In fact, illness may not be diagnosed at all until damage to nerves and blood vessels has begun Most of what is known about symptoms, treatments, and complications of type 2 comes from research with adults For this reason, health care providers have to do more guesswork working with younger patients Another challenge is that many children with type 2 belong to families that as a whole eat poorly and exercise little Changing the childs lifestyle often means working to change the entire family Teenagers tend to resist treatment, so doctors have to be creative in finding a plan that the patient agrees to follow Young patients typically need frequent re-teaching, too Finally, type 2 diabetes in younger people is such a new trend
that some insurance plans do not cover the special care that may be required Parents may have a hard time getting insurance to pay for this care

Despite these challenges, treatment for young patients is very important They have many years ahead of them, and the longer a patient has diabetes the more risk there is of complications

Part 4: How do researchers study diabetes?

Jerry Stackhouse
Jerry Stackhouse plays guard for the Washington Wizards, the professional basketball team in Washington, DC And he is one of the top players in the NBA His life is a dream come true But Stackhouse has seen how diabetes can cut lives and dreams short Two of his older sisters, Delois and Jean, died from complications from diabetes Now his mother, Minnie, and his father, George, have been diagnosed Stackhouse says, People think diabetes is an old peoples disease and that it is not really a deadly disease But because of my sisters, I have seen how it can kill people in their 40s He has started his own charity called the Triple Threat Foundation to fund research and raise awareness of diabetes Stackhouse has filmed public service announcements for television and spoken about diabetes before
Congress Managing diabetes, he has said, is tougher than anything I do on the basketball court Stackhouse grew up in small town in eastern North Carolina called Kinston Because of his sisters, he thought insulin shots were normal I guess thats because I grew up the disease It was just something that people did, like pouring milk into cereal My sister had to take shots I didnt think it was anything major, he says And like many people, he thought that diabetes came from eating too much sugar In fact, Stackhouse says, sugar is what people in Kinston often called diabetes Bad diet may increase your chances of getting diabetes, but sugar doesnt cause it It became clear to Stackhouse just how serious diabetes could be when his sister started to suffer complications Delois had her left foot amputated Jean suffered both kidney failure and hepatitis
Stackhouse, continued on next page

Diabetes: The Science Inside
One of Stackhouses main goals is to raise awareness of diabetes in the African, Latino and Native American communities The disease hits those groups especially hard The statistics are shocking Thirteen percent of all adult African Americans have diabetes, 10 percent of all
adult Latinos, and, by some estimates, 15 of all adult American Indians and Alaska Natives Stackhouse thinks one place to start is to educate people about symptoms so they will get a diagnosis, early treatment, and advice about how to control the disease If people have blurry vision or find that that they have to go to the bathroom a lot, they should go get checked out, he says Stackhouse does not have diabetes now, but he knows he is at risk because of his family history He is careful about what he eats As a pro basketball player, he is very active, to put it mildly But once his playing days over, Stackhouse knows he is going to be have to careful Im definitely not out of the woods with this disease

Part 5: Lets take control over type 2 diabetes
How you can help
Type 2 diabetes does not have to throw its shadow over the lives of so many people The rising number of cases can be reversed, but this is not a task for the medical workers alone How can any one person help? Here are some ideas Look on page 39 for resources to get you started Educate yourself about type 2 diabetes You have begun to educate yourself by reading this information Keep educating yourself Go to your
library and ask for information on diabetes Use your computer, or a computer at the library, to search the Internet Librarians will help you in your Internet search if you need it Then share your knowledge with other members of your family and community Recognize that you can make a difference in your own health and the health of your family The two key preventions — healthy eating and exercise — dont happen in the doctors office Learn about and practice the habits that can keep diabetes away from your family

Clinical study proves the value of tight control
In 1993, a revolution occurred in the treatment of diabetes That year a 10-year study was completed, called the Diabetes Control and Complications Trial DCCT The trial involved 1,441 people with type 1 diabetes who were treated at 29 medical centers across the US and Canada Volunteers were randomly placed in two groups The first group received standard treatment This was the best care known for the time, which involved injecting insulin once or twice per day The second group followed an experimental treatment known as tight control This meant the volunteers tested their blood frequently throughout the day and ate food or
injected insulin as needed to keep blood sugar stable The study proved beyond a doubt that excess blood sugar is the source of the problems that come with diabetes It proved that tight control of blood sugar can delay and reduce complications In fact, the differences between the two groups was dramatic Eye disease was 76 percent lower in the tight control group Nerve disease was 60 percent lower, and kidney disease was 50 percent lower The study also showed that some control, even if it could not be called tight, was better than no control A follow-up study showed that the benefits of control last for years Another major study came to the same conclusions for people with type 2 This was the United Kingdom Prospective Diabetes Study UKPDS It was a twenty-year study with patients in England, Ireland, and Scotland Tight control is not a perfect solution to the problems of diabetes It requires attention and effort People who maintain tight control are more likely to suffer from low blood sugar problems hypoglycemia Even so, these studies show that the benefits of tight control are far greater than the drawbacks

Diabetes: The Science Inside
Arrange for testing if you or family
members are at risk for diabetes Risk factors include a family history of diabetes, obesity, membership in a minority racial or ethnic group, age, and symptoms see page 4 for a description of symptoms Ask your doctor for diabetes screening If you have diabetes, accept the changes that you must make A diabetes diagnosis means changes in the way you live You have to watch your diet and take up exercise, pay careful attention to your body, and go in for health check-ups You may have to take medicine You cannot look at these changes as annoying or optional They have to become part of your daily habits They are the necessary steps only you can make to preserve your health Seek good prenatal care for women in your community When diabetes is avoided or controlled during pregnancy, complications at delivery are reduced Work to educate women of child-bearing age about diabetes Join efforts to make prenatal care available to all who need it Help bring diabetes prevention programs into your community Learn from the prevention programs that have succeeded in communities like yours Work with a local organization to create a prevention program that fits your community To obtain a small grant to
support your community prevention program, see Healthy People Library Project in the Resources list on page 39 Encourage schools to lead in diabetes prevention Ask your local schools to review lunch menus and vending machine products to make sure healthful foods are available to students Find out if schools provide enough gym classes, recess play, and after-school activities so students get the exercise they need Help plan prevention programs for students Volunteer for diabetes or diabetes prevention trials Obtain information on upcoming trials Volunteer yourself for a trial, and promote these opportunities to members of your community Find out if your community can be a site for a research trial on prevention Encourage young people to seek careers in diabetes research, treatment, and prevention Ask the local school system to provide challenging college prep science classes Help young people find the scholarships and college courses that lead to careers in diabetes

Part 5: Lets take control over type 2 diabetes

Huge clinical trial shows that low-fat diet and exercise reduce risk for type 2 diabetes
Are you overweight? Do you have impaired glucose tolerance? Then you are at
high risk for type 2 diabetes But heres what you can do to reduce your risk: lose some weight and take up exercise Even small changes in weight and exercise can protect you This news comes from the Diabetes Prevention Program, a multi-year study conducted at several hundred clinics in the US and Canada The study involved more than 3,000 overweight volunteers with impaired glucose tolerance A cross-section of people took part, including people over age 60, women with a history of gestational diabetes, people with close relatives who have the disease, and members of minority groups with high rates of type 2 diabetes

One set of volunteers was given advice and support to lose weight by eating a low-fat diet and exercising for about a half-hour five days a week Most of the volunteers exercised by walking Over three years, this set of volunteers developed diabetes at a rate that was 58 percent lower compared to another set who received standard health advice but no extra diet or exercise help Twice as many of these volunteers regained normal glucose tolerance, compared to the volunteers who did not receive the extra help Another group of volunteers received health advice and took an
insulin-regulating medicine called metformin They reduced their risk by 31 percent compared to the volunteers who did not receive extra help Researchers continue to follow the progress of the volunteers to find out whether the benefits of good diet and exercise last over time

Ruby Wolf: A tireless campaigner against diabetes
I lost my parents to diabetes, says Ruby Wolf What I saw with my parents is not what I want for my community Wolf is a member of the Zuni tribe that lives in the high desert of New Mexico Traditionally Zuni people were lean and athletic Runners often traveled long distances to reach farm fields or to carry messages between villages Lard and sugar, cars, sit-down habits, and other modern influences have brought a huge change to the Zuni Many now fall victim to obesity and its companion, type 2 diabetes Some 1,400 Zuni are diabetic in a tribe of only 10,000 Thats three times the rate for the general population Wolf believes that education is key to turning this around–education about type 2 diabetes and about healthful Zuni traditions As director of a local nutrition clinic, Wolf works with other activists to re-introduce healthy practices into daily life A
majority of Zuni women once again breastfeed their infants New playgrounds have been
Wolf, continued on next page

Diabetes: The Science Inside
constructed The community drinks low-fat milk instead of whole, and bottled water is now stocked in vending machines The Zuni gym is constantly busy with group workout sessions and individual users of the weights and stationary bikes Theres also the Zuni Fitness Series Runs, walks, and other fitness events take place each month starting in the spring and building up to a 25-mile reservation relay in August By offering a wide variety of events, Wolf says, weve been able to motivate people who are not necessarily interested in competing at sports or running There used to be a charge to take part in the Fitness Series, but thats been dropped Now participants are asked for something else: information The registration form asks about body mass index, risk factors for diabetes, and other health information Wolf explains that these data, along with follow-up data collected at future events, will be used to measure the communitys progress toward fitness Meanwhile Wolfs nutrition clinic continues to educate about wellness through a Healthy
Lifestyles project The project puts out fitness information through radio, bulletin boards, articles, and other means, but especially through the fourteen staff people who make personal visits to community members On these visits staff members are able to spend more time educating clients compared to health workers in a medical setting Also, they are able to help entire families learn what to do to stay fit, so the burden of change is not on one person alone The Healthy Lifestyles project recently succeeded in getting a wellness curriculum included in the public schools at all grade levels Another recent success is a grant to the schools for fruit and vegetable snacks, so children are less tempted by junk food Wolf says that what has really helped get the message across is providing educational materials in the Zunian language Some people have told her, I never knew that until I heard it in Zuni What keeps Wolf inspired are those moments when people are having fun staying in shape Five hundred-plus walkers out at 7:30 in the morning, she says What motivation Shes also inspired by the need to undo the myth that to be Zuni means to get diabetes We say no, this is not what has to
happen, this is not the belief we should have anymore, she says Were going back to tradition and if we do that well have healthier lifestyles

Part 5: Lets take control over type 2 diabetes

Questions to ask your doctor or nurse about diabetes
If you have not been diagnosed with diabetes
Am I at risk for diabetes? Should I be tested for diabetes? What is my body mass index BMI? Does my BMI suggest that I might be at increased risk for diabetes? What are the symptoms of diabetes that I should watch out for? What do I need to do differently to prevent diabetes? Can you help me lose weight? Can you tell me how to eat better? Can you help me get started on an exercise plan?

If you have been diagnosed with diabetes
What can be my short-term goals for control of the diabetes? What can be my long-term goals? What is my treatment plan? Who can help me learn self-management of my diabetes? What medications will help control my diabetes? What do I need to do differently to follow my treatment plan? What other specialists do I need to see? What is my schedule for check-ups? If I get pregnant, how will diabetes affect my baby and myself? Can you help me locate a clinical trial to join?
When you volunteer for a research study, you may be able to improve your own health or the health of future generations But before you volunteer, do some research yourself Find out if the study is the right for you

Diabetes: The Science Inside

Taking part in research studies: What questions should you ask?
By law, researchers must have your informed consent before they can include you in a study This means: You agree to participate You know what the study is about You know what your rights are You know how you will be protected from harm Here are important questions you should ask of anyone who wants you or a loved one to be part of a research study on diabetes What is the study about? Who put this study together? How can people like me share their ideas as you do this study? Who is going to be in this study? What will I get out of this study? How will I be protected from harm? How will my privacy be protected? What do I have to do in this study? What will happen with the information you collect, and the research results, after the study is over? Do you have a patient advocate — someone who can help me understand this information? These questions are adapted from a more
detailed brochure called Taking Part in Research Studies — What Questions Should You Ask? You can view it on-line by typing Taking Part in Research Studies into the Quick Search box at wwwcdcnpinorg/ You also can order copies of Taking Part in Research Studies item number D025 from: National Prevention Information Network PO Box 6003 Rockville, MD 20849-6003 1-800-458-5231

How much time do I have to decide whether I want to participate?

Resources
American Association of Diabetes Educators Promotes diabetes education and patient care 100 West Monroe, 4th Floor Chicago, IL 60603 312 424-2426 wwwaadenetorg American Diabetes Association Promotes diabetes prevention and treatment and advocates for improved quality of life for people with diabetes National Service Center 1701 North Beauregard Street Alexandria, VA 22311 1-800-DIABETES or 703 549-1500 ClinicalTrialsgov A Web-based resource for finding clinical trials in need of volunteers wwwclinicaltrialsgov Select the diabetes topic to search for diabetes-related trials Comprehensive Health Information Database A web-based service that combines resources on diabetes and other diseases from several federal agencies A service of
the National Institutes of Health chidnihgov/simple/simplehtml Diabetes Research and Training Centers Diabetes Endocrinology Research Centers Two types of diabetes research centers supported by the National Institute of Diabetes and Digestive and Kidney Diseases NIDDK wwwniddknihgov DPT-1 Clinical Centers Enrolls volunteers into the Diabetes Prevention Trials Free diabetes testing for volunteers is provided through hundreds of screening centers in the US and Canada 1-800-HALT-DM1

Diabetes: The Science Inside
Healthy People Library Project A nationwide health promotion and disease prevention campaign sponsored by the Department of Health and Human Services One of the goals of the campaign is to reduce health disparities Office of Disease Prevention and Health Promotion 200 Independence Avenue SW, Room 738G Washington, DC 20201 800 367-4725 wwwhealthgov/healthypeople For information on the Healthy People Microgrant program that finances community-based prevention activities, go to the following web site: wwwhealthgov/healthypeople/implementation/community/ Indian Health Service National Diabetes Program Supports and promotes health efforts that prevent and control diabetes among
Native Americans Indian Health Service 5300 Homestead Road, NE Albuquerque, NM 87110 505 248-4182 Medlineplus A comprehensive source of health information provided by the National Library of Medicine wwwnlmnihgov/medlineplus/diabeteshtml National Center for Chronic Disease Prevention and Health Promotion Promotes the transfer of research knowledge into actual prevention and treatment strategies Provides information to the general public Centers for Disease Control and Prevention Division of Diabetes Translation Mail Stop K-10 4770 Buford Highway, NE Atlanta, GA 30341-3717 1-800-CDC-DIAB wwwcdcgov/diabetes

Resources
National Diabetes Education Program NDEP A federally-sponsored initiative that involves public and private partners to improve the treatment and outcomes for people with diabetes, to promote early diagnosis, and to prevent the onset of diabetes NIDDK National Institutes of Health Bethesda, MD 20892-2560 1-800-438-5383 http://wwwndepnihgov/ National Diabetes Information Clearinghouse A source of information for professionals and for the general public A clearinghouse of NIDDK 1 Information Way Bethesda, MD 20892-3580 1-800-860-8748 or 301 654-3327
wwwniddknihgov/health/diabetes/diabeteshtm National Eye Health Education Program Sponsors eye health education programs to promote early diagnosis and treatment of diabetic eye disease National Eye Institute Box 20/20 Bethesda, MD 20892-3655 1-800-869-2020 health professionals 301 496-5248 general public wwwneinihgov National Heart, Lung, and Blood Institute Information Center Provides patient education and professional materials on topics of interest to diabetes patients such as cholesterol, high blood pressure, heart disease, exercise, and obesity PO Box 30105 Bethesda, MD 20824-0105 301 592-8573 wwwnhlbinihgov/health/infoctr

Diabetes: The Science Inside
National Kidney and Urologic Diseases Information Clearinghouse Provides information about kidney disease as it relates to diabetes 3 Information Way Bethesda, MD 20892-3580 1-800-891-5390 or 301 654-4415 wwwniddknihgov/health/kidneys/kidneyhtm National Oral Health Information Clearinghouse Provides information for the oral health of special care patients such as diabetics 1 NOHIC Way Bethesda, MD 20892-3500 301 402-7364 wwwnohicnidcrnihgov Native American Research Centers for Health Research centers that link the Native
American community with health research and that work to increase the number of Native American scientists and health professionals National Institute of General Medical Sciences National Institutes of Health 45 Center Drive MSC 6200 Bethesda, Maryland 20892-6200 301 496-7301 wwwnigmsnihgov New York Online Access to Health A searchable health information resource in English and Spanish wwwnoah-healthorg/indexhtml Office for Human Research Protections A source of information on the guidelines and ethics of research studies with humans Department of Health and Human Services The Tower Building 1101 Wootton Parkway, Suite 200 Rockville, MD 20852 301 496-7005 http://ohrposophsdhhsgov/addresshtm

Resources
Office of Minority Health Resource Center Serves as a national resource and referral service on minority health issues, including diabetes Affiliated with the US Department of Health and Human Services PO Box 37337 Washington, DC 20013-7337 1-800-444-6472 wwwomhrcgov/omhrc/ National Center on Minority Health and Health Disparities Promotes the health of racial and ethnic populations through research and education and through support of minority involvement in research careers
Affiliated with the National Institutes of Health 6707 Democracy Boulevard Suite 800 MSC 5465 Bethesda, MD 20892-5465 1-800-444-6472 301- 402- 1366 wwwncmhdnihgov Weight-Control Information Network Health information and educational materials on weight loss A clearinghouse of National Institutes of Diabetes and Digestive and Kidney Diseases NIDDK 1 WIN Way Bethesda, MD 20892-3665 1-800-WIN-8098 or 301 984-7378 wwwniddknihgov/health/nutrit/winhtm Veterans Health Administration Diabetes Program Works to ensure state-of the-art care for diabetes patients served by veterans hospitals Program Chief, Diabetes Veterans Health Affairs 810 Vermont Avenue, NW Washington, DC 20420 202 273-8490

Bibliography
American Diabetes Association American Diabetes Association Complete Guide to Diabetes, 2nd edition Alexandria, VA: American Diabetes Association, 1999 Centers for Disease Control and Prevention Healthy People 2010: Objectives for Improving Health Chapter 5: Diabetes, Atlanta, GA — Update: Prevalence of overweight among children, adolescents, and adults–United States Morbidity and Mortality Weekly Report 46 09: 199202, March 7, 1997 Connolly, Ceci Deaths from heart disease, cancer,
AIDS, declined in 99 Washington Post p A3, June 27, 2001 Cook, VC and J S Hurley Prevention of type 2 diabetes in childhood Clinical Pediatrics 372: 123127, Feb 1998 Diabetes Dateline Diet and exercise delay diabetes and normalize blood glucose Spring 2002, accessed October 24, 2002 http://wwwniddknihgov/health/diabetes/spri02/1htm Diabetes Insipidus Foundation, Inc website Accessed October 15, 2002 http://diabetesinsipidusmaxinternet/ Diabetic Retinopathy Foundation Microvascular disease Accessed October 22, 2002 http://retinopathyorg/info01htm Doughty, R The promise of islet cells Diabetes Forecast 2000 53 3: 5460, 2000

Diabetes: The Science Inside
Drug-netcom Information on Therapies: Oral Treatments Altruis LLC, Vestavia Hills, AL Field, Alison Impact of overweight on the risk of developing common chronic diseases during a 10-year period Archives of Internal Medicine 2001 161: 15811586, 2001 Flegal KM et all Overweight and obesity in the United States: prevalence and trends, 19601994 International Journal of Obesity 22: 3947, 1998 Florence, Joe A and Yeager, Bryan F Treatment of Type 2 diabetes mellitus American Family Physician 5910: May 15, 1999 Lodewick, Peter A, June
Biermann and Barbara Toohey The Diabetic Man 3d ed Chicago: Lowell House, 1999 MEDLINEplus Medical Encyclopedia: Diabetes insipidus Accessed October 15, 2002 http://wwwnlmnihgov/medlineplus/ency/000377htm Medscape Position Statements: Screening for type 2 diabetes, South Med J 95 1:35-49, 2002 Southern Medical Association Accessed October 24, 2002 http://wwwmedscapecom/viewarticle/426920_4 Morris, Christine Stem Cells May Move Diabetics Closer to Cure Diabetes Research Institute Web site wwwdrinetorg National Eye Institute Facts about diabetic retinopathy Accessed October 22, 2002 http://wwwneinihgov/health/diabetic/retinopathyhtm National Institutes of Diabetes and Digestive and Kidney Diseases NIDDK, National Institutes of Health Diabetes Control and Complications Trial DCCT NIH Publication No 97-3874, September 1994

Bibliography — Diabetes in African Americans NIH Publication No 02-3266, May 2002 — Diabetes in American Indians and Alaska Natives NIH Publication No 02-4567, May 2002 — Diabetes in Asian and Pacific Islander Americans NIH Publication No 02-4667, May 2002 — Diabetes in Hispanic Americans NIH Publication No 02-3265, May 2002 — National Diabetes Statistics
NIH Publication No 02-3892, March 2002 — Diabetic Neuropathy: The Nerve Damage of Diabetes NIH Publication No 97-3185 July 1995 — Hypoglycemia NIH Publication No 98-3926 May 1995 — Kidney Disease of Diabetes NIH Publication No 01-3925 July 1995 Updated April 2001 — New Products offer blood glucose testing without lancets Diabetes Dateline Fall 2000 — NIH launches first study to examine long-term effects of weight loss and exercise in type 2 diabetes Press Release June 25, 2001 — Research Advances and Directions A New Era of Hope chapter — The Pima Indians: Pathfinders for Health NIH Publication No 95-3821 Oxford Centre for Diabetes, Endocrinology Metabolism, Diabetes Trial Unit Better blood pressure control Accessed 3/6/03 http://wwwdtuoxacuk/ukpds/resultshtml Pinhas-Hamiel, Orit and Zeitler, Phil Type 2 diabetes: not just for grownups anymore Contemporary Pediatrics, v18i1 p 102, January 2001 Spiegel, Allen M Challenges in Health Disparity in the New Millenium: A call to action Speech to the National Conference sponsored by the Office of Research on Minority Health, NIH, April 2000

Diabetes: The Science Inside
Squires, Sally Think youre trim enough? Think again
Washington Post, Health Section p 5, July 17, 2001 Getting A Jump on Diabetes: Earlier screening urged for people at high risk Washington Post F1F5, August 28, 2001 Stuart, Charles A et al Acanthosis nigricans as a risk factor for non-insulin dependent diabetes mellitus Clinical Pediatrics 372: p7377, February 1998 Tuomilehto, Jaakko et al Finnish Diabetes Prevention Study Group: Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance New England Journal of Medicine 344:13431350, 2001 University College London Hospitals Lipid management in diabetes Accessed 3/6/03 wwwuclhorg/services/diabetes/protocol/complications/ lipid_mgmtshtml University of Arizona Native American Research and Training Center Type 2 diabetes: Whats next? NARTC conference looks at impact on minority youth NARTC newsletter DATE University of North Carolina at Chapel Hill, Center for Health Promotion Disease Prevention New LeafChoices for Healthy Living with Diabetes Diabetes Dateline 2001 US Department of Health and Human Services Diet and exercise dramatically delays type 2 diabetes; diabetes medication metformin also effective HHS News, August 8,
2001

Glossary
Note: in the definitions below, some words are in italics These words have their own entries in this glossary acanthosis nigricans: dark and thickened patches of skin, usually on the neck, under the arms, or inside the elbows These patches can be a symptom of diabetes They tend to appear in obese members of racial and ethnic minority groups Action for Health in Diabetes: A ten-year study of 5,000 diabetes patients, nicknamed Look AHEAD The study seeks to find out if the complications of type 2 diabetes can be reduced through weight loss and exercise action time: a term that describes how quickly an insulin product takes effect and how long it lasts adult-onset diabetes: a name for type 2 diabetes It is no longer used by health professionals, because the illness affects young people as well as adults amputation: the removal of a limb because it is diseased or decayed It is one of the possible complications of diabetes arteries: the blood vessels through which blood moves away from the heart Other blood vessels, called veins, carry blood back to the heart blindness: a condition of being unable to see It is one of the possible complications of diabetes The form of
blindness linked to diabetes is called retinopathy blood glucose meter: a machine that analyzes a tiny blood sample placed on a test strip to produce a measurement of blood sugar blood sugar: glucose in the blood blood pressure: the force of the heart as it pushes blood through the arteries blood vessels: the pipelines through which blood travels to all parts of the body body mass index BMI: reflects the ratio of height and weight An adult with a BMI of 25 or higher may be overweight and therefore at increased risk of diabetes To calculate BMI, go to http://wwwcdcgov/ nccdphp/ dnpa/bmi carbohydrates: foods that contain sugars or starches cardiovascular disease: the combination of disease of the blood vessels and disease of the heart It is one of the possible complications of diabetes cholesterol: a wax-like substance found in human cells Some cholesterol is needed for healthy cells, but too much can build up in blood vessels and block the flow of blood chronic: long-lasting and on-going clinical trials: research tests using people that are performed to test the success of a medical treatment, medicine, or prevention strategy A clinical trial usually is conducted only after the
treatment has been successful in the laboratory and on animals complications of diabetes: health problems that often develop in people with diabetes These complications include heart disease, nerve damage, kidney disease, blindness, amputations, skin problems, and other health conditions

Diabetes: The Science Inside
complications of pregnancy: problems that are not expected in a healthy pregnancy These include birth defects, illness at birth for the mother or baby, injury or death to the newborn, and injury or death to the mother Complications of pregnancy are more likely if the mother has diabetes dentist: a doctor who specializes in the teeth and gums Diabetes Control and Complications Trial DCCT: a ten-year study, completed in 1993, that proved the value of tight control over blood sugar to avoid and delay complications of type 1 diabetes diabetes educator: a health care professional who provides self-management training and support to patients so they can control their diabetes diabetes mellitus: a set of illnesses caused by improper amounts of glucose in the blood A more formal name for diabetes diabetes pills: medicine taken in pill form that helps promote the action of
insulin These pills may be prescribed to patients with diabetes Diabetes Prevention Program: a multi-year study of patients at risk for type 1 and type 2 diabetes that is testing strategies for preventing the illnesses diabetic acidosis: a condition in which large quantities of acids are dumped into the bloodstream following the breakdown of fat cells The acids can act like poison and lead to shock, difficulty breathing, and coma diagnosis: a professional medical opinion, based on an exam and history of the patient, about what is causing symptoms of illness dialysis: the use of a machine to perform the function of the kidneys, which is to clean the blood diastolic pressure: the pressure in the arteries when the heart rests between beats It is the second number reported in a blood pressure reading dietician: a health care professional who advises patients on diet and eating epidemic: a rapidly spreading and increasing problem, such as a disease which is gaining hold in more and more people exercise specialist: a health care professional who trains and advises patients in physical activity appropriate for their condition fasting glucose test: a test for diabetes that measures blood
sugar This test requires the patient to stop eating several hours beforehand genes: units of hereditary information contained in each cell of the body genetic predisposition: the term for a persons increased likelihood of developing some trait or illness because he or she carries certain genes genetics: the field of science that looks at how genes are passed down from one generation to another to influence traits gestational diabetes: a form of diabetes that appears during pregnancy glucose: a form of sugar found in food that is the bodys main fuel glucose challenge: a test to measure glucose that involves drinking a standard dose of oral glucose and fasting for a short period This test is given to screen for diabetes glucose tablets: small pills containing glucose that are a convenient and quick way to increase blood sugar gum disease: disease of the tissues that hold the teeth in place It is one of the possible complications of diabetes health disparity: the uneven impact of a health problem that may occur between groups of people

Glossary
heart attack: a failure of the heart to perform its job of pushing blood through the blood vessels heart disease: disease of the heart,
the organ that pumps blood through the body It is one of the possible complications from diabetes high blood pressure: a condition in which blood is pushed through the bodys blood vessels at greater force than normal It is one of the possible complications from diabetes, and can lead to tiredness, heart attack, stroke and other health problems High blood pressure is also known as hypertension hormone: a protein produced by an organ of the body to trigger activity in other locations Insulin is an example of a hormone hydrogenated fat: vegetable oils that have been processed into solid fats This type of fat should be avoided by the person with diabetes hyperglycemia: a condition in which there is an excess of blood sugar hyperinsulinemia: a condition in which a person has high levels of insulin in the blood This condition indicates a risk for developing type 2 diabetes hypertension: another term for high blood pressure hypoglycemia: a condition in which there is too little blood sugar immune system: the coordinated responses of the body that serve to protect it against outside invaders such as viruses and bacteria impaired fasting glucose or impaired glucose tolerance: a condition in
which a person has blood sugar levels that are higher than normal but not high enough to confirm a diagnosis of diabetes This condition indicates a risk for developing type 2 diabetes informed consent: a volunteers agreement to participate in a research study, based on a full and complete understanding of what the study is about This includes information on the risks for the volunteer, the rights of the volunteer, and the ways in which the volunteer will be protected from harm insulin: a hormone released by the pancreas that triggers the opening of body cells so that glucose may enter and be used for energy insulin reaction: a condition in which there is not enough glucose in the blood, leading to symptoms ranging from weakness and strange behavior to loss of consciousness This condition is also called hypoglycemia insulin resistance: actions by the cells to oppose insulin, which seeks to open the cells so that glucose may enter insulin sensitizers: medicine that makes cells more receptive to insulin This medicine may be subscribed in pill form to patients with diabetes insulin-dependent diabetes: a form of diabetes in which the pancreas has stopped producing insulin so that
patients must inject insulin daily It is also called type 1 diabetes islet cells: cells that are small, islandlike areas in the pancreas that produce insulin and other hormones They are also known as islets of Langerhans juvenile diabetes: a name for type 1 diabetes It is no longer used by health care professionals, because it affects adults as well as young people ketones: strong acids created from the breakdown of fat

Diabetes: The Science Inside
kidney disease: a disease of the kidneys, the pair of organs that clean the blood The disease can lead to kidney failure It is also called nephropathy It is one of the possible complications from diabetes kidneys: the pair of organs that have the job of filtering the blood mental health professional: a health care worker who provides emotional counselling and medicines for mood to patients metformin: medicine that slows down glucose production in the liver and speeds glucose uptake by the cells This medicine may be prescribed in pill form to patients with diabetes nephropathy: a disease affecting the kidneys It is also called kidney disease It is one of the possible complications from diabetes nerves: the network of cells that
transmit signals from all parts of the body to the brain and back nervous system disease: a disease affecting the nerves It is also called neuropathy It is one of the possible complications from diabetes neuropathy: a disease affecting the nerves Another term for it is nervous system disease It is one of the possible complications from diabetes noninsulin-dependent diabetes: a form of diabetes in which the pancreas does not produce enough insulin and the cells resist the action of any insulin that is produced With this illness, patients often do not have to inject extra insulin It is also called type 2 diabetes obesity: the condition of being overweight Obesity is diagnosed in patients who are more than 20 percent over ideal body weight ophthalmologist: a physician or MD who specializes in the eyes optometrist: a doctor or eye care specialist who tests eyes, detects eye problems, prescribes lenses, and treats some eye conditions oral hypoglycemics: medicines that work on the pancreas to increase insulin production These medicines may be prescribed in pill form to patients with diabetes oxygen free radicals: leftovers made when the body pulls oxygen from cells These radicals can
attach to other cells, damaging them pancreas: the organ of the body that produces insulin and other hormones pharmacist: a health care professional who fills prescriptions, dispenses medicines, and sells or rents medical tools and equipment podiatrist: a doctor who specializes in the feet prevalence: a statistical term that means the number of cases in a standard sample, such as 100 or 1,000 primary doctor: the doctor in charge of a patients care prognosis: A professional medical opinion, based on exams and medical findings, about the patients likely future health random glucose test: a test for diabetes that measures blood sugar For this test, it does not matter when the patient last ate retina: a light-sensing part of the eye retinopathy: a disease of the eyes retina that can lead to blindness It is one of the possible complications of diabetes saturated fat: fat from animal products, such as butter and lard and

Glossary
the fat on meat This type of fat should be avoided by the person with diabetes self-management: the behavior of a patient that is required to follow a treatment plan self-management training: the education and support a patient receives from health care
professionals so that he or she has the skills and confidence needed to follow a treatment plan starch blockers: medicine that slows digestion so blood sugar does not rise too quickly after eating This medicine may be subscribed in pill form to patients with diabetes stem cells: unspecialized cells that have the ability to grow into many different kinds of cells They are obtained from embryos or from adult cells Stem cell research seeks to create insulin-producing cells that could be transplanted into diabetes patients stroke: damage to the blood vessels in the brain that can result in the inability to speak or move part of the body symptom: a sign of a problem such as a disease systolic pressure: the pressure in the arteries when the heart beats It is the first number reported in a blood pressure reading thrifty gene theory: a theory that suggests a gene or genes evolved in ancient populations to help them maximize the storage of energy from food This would have helped them survive through periods of starvation In modern society, people who have inherited these genes may gain weight very easily, leading to a higher risk for type 2 diabetes tight control: a treatment for diabetes
that involves keeping close watch over blood sugar and taking insulin or eating as necessary to keep those levels steady toxemia: an illness caused by the build-up of poisons in the bloodstream Diabetes can sometimes trigger toxemia during pregnancy treatment plan: a set of steps for a person with diabetes to follow to maintain good health Ideally, the treatment plan is put together by a team of health care professionals working with a patient triglycerides: a form of fat that the body obtains from food and uses for energy type 1 diabetes: an illness in which the pancreas has stopped producing insulin, leading to imbalances in blood sugar type 2 diabetes: an illness in which the pancreas does not produce enough insulin and the cells resist the action of any insulin that is produced United Kingdom Prospective Diabetes Study: A twenty-year study with patients in England, Ireland, and Scotland that proved the value of tight control over blood sugar to avoid and delay complications of type 2 diabetes

Acknowledgements
Project Advisors
Philip Abelson, PhD American Association for the Advancement of Science AAAS Yolanda Cuesta Cuesta Multicultural Consulting Yolanda George American
Association for the Advancement of Science AAAS Robert D Goldman, PhD Northwestern University Medical School Max Gomez, PhD WNBC, Health Science Editor Beatrix Betty Ann Hamburg, MD Cornell University Medical College Marcia Harrington District of Columbia Public Library Constance Hendricks, PhD Chair, Graduate Nursing Programs Southern Univ and AM College School of Nursing Eric Jolly, PhD Education Development Center Inc EDC Betty Lawrence Rochester Public Library, New York Audrey Manley, PhD President Emerita, Spelman College Marsha Lakes Matyas, PhD The American Physiological Society Sandra Negro Senior Librarian, Wheaton Library, Maryland

Acknowledgements
Delores Parron PhD Scientific Advisor for Capacity Development Office of the Director, National Institutes of Health Joseph Perpich, MD PhD JG Perpich, LLC Marcy Pride MLS, MA Director, Oyer Memorial Library Washington Bible College and Capital Bible Seminary, Lanham, Maryland Josefina Tinajero, EdD Associate Dean -College Of Education University of Texas at El Paso

Diabetes Content Reviewers/Advisors
James R Gavin, III, MD, PhD President, Morehouse School of Medicine Saul Malozowski, MD, PhD, MBA Senior Advisor for
Clinical Trials and Diabetes Translation Division of Diabetes, Endocrinology, and Metabolic Diseases National Institute of Diabetes and Digestive and Kidney Diseases Samuel J Casella, MD Section Chief, Pediatric Endocrinology Dartmouth-Hitchcock Medical Center

Project Staff and Consultants
Shirley M Malcom, Principal Investigator Maria Sosa, Co-Principal Investigator and Project Director Lisa Boesen, Project Manager Mary Chobot, PhD, Library Consultant and Project Evaluator Ann Williams, Art Director Catherine Baker, Writer Betty Calinger, Editor Maggie Sliker, Photo Researcher Heather Beecheler, Chickona Royster: Project Associates Special thanks go to Nathan Bell, Harriet Pickett, and Kirsten Fearnley for their assistance with the development of this book series

Photo Credits:
Cover Page 1 Page 3 Page 6 Page 7 Page 8 Page 9 Page 11 Page 13 Page 17 Page 18 Page 20 Page 21 Page 23 EyeWire Images EyeWire Images EyeWire Images Image Club Graphics Morehouse School of Medicine, Atlanta Morehouse School of Medicine, Atlanta Getty Images Getty Images Sharon Hoostraten Photography Getty Images EyeWire Images Artville LLC EyeWire Images Comprehensive Childhood Diabetes Center at
Childrens Hospital Los Angeles Page 29 Page 30 Page 31 Page 32 Page 35 EyeWire Images PhotoDisc Inc Washington Wizards Washington Wizards Zuni WIC Healthy Lifestyles Program

AMERICAN ASSOCIATION FOR THE ADVANCEMENT OF SCIENCE 1200 New York Avenue, NW Washington, DC 20005 202-326-6670 wwwaaasorg

Source:utmb.edu

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Diabetes. H E A L T H Y P E O P L E L I B doctor or nurse about diabetes. 38 types of diabetes, but they all have. to do with the body’s inability to …

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