May 11, 2012

Diabetes mystified researchers and doctors for 3,000 years

In the 16th century famed Swiss physician Paracelsus theorized that salt in the urine caused diabetes.

With an epidemic of obesity looming in 2012, health care providers like Kaiser Permanente face the sad and intimidating prospect of a burgeoning caseload of patients diagnosed with diabetes, a debilitating disease that unless treated will mercilessly kill its victims, young and old.

A disease that baffled physicians until the early 20th century, diabetes is reasonably well understood today, and research has tied its rising incidence to equivalent increases in overweight and obesity. Treatment is sophisticated and can allow for a normal and long life. But getting to this level has been a long road.

Scientists first identified diabetes about 3,000 years ago. In 1552 B.C. an Egyptian physician described it as “polyuria” or frequent urination. In the 1st century, Greek physician Aretaeus dubbed it “the melting down of flesh and limbs into urine.” Until the 11th century, the disease was diagnosed by “water tasters” who drank the urine of people thought to have diabetes to see if the excretion was sweet like honey. In Latin, diabetes is siphon and mellitus is honey or sweet, hence the disease name that endures to this day — Diabetes Mellitus.

In the 16th century, famed Swiss-born physician and astrologist Paracelsus studied diabetes and theorized that salt in the urine caused the disease. (Wrong! It was that other white substance.) French pharmacist and hygienist Apollinaire Bouchardat was spurred to experimentation with diet after noticing diabetes symptoms disappeared when food was rationed in Paris during the Franco-Prussian War in the 1870s.

In the late 19th century Italian diabetes specialist Catoni is said to have locked up his patients to get them to follow their special, low-carbohydrate diets. Before the 1920s, a diagnosis of diabetes was a death sentence for most patients. They usually faded away and died within about 18 months. But a grasp on the underlying medical condition remained elusive.

19th century scientific discoveries confirmed the problem — a diabetic’s pancreas was not manufacturing the normal hormone, now known as insulin, needed to properly turn food into energy. Food converted to sugar (glucose) leaked into the urine because the body could not absorb it from the blood. Researchers began to experiment with dogs whose pancreases had been removed so scientists could better understand how the lack of insulin affected metabolism.

1920s development of insulin revolutionizes diabetes care

Unmanaged diabetes often leads to heart disease. Fotosearch image

Eventually researchers developed experimental pancreatic extracts that allowed diabetic dogs to properly digest food. In 1921, Frederick Banting, a young Canadian surgeon, and his assistant Charles Best, kept a diabetic dog alive for 70 days by injecting it with canine pancreatic extract. The same year, Dr. Banting and other physicians refined the experimental insulin and gave it to a young boy dying of diabetes. It seemed like a miracle when the boy’s blood sugar dropped to within normal limits in 24 hours.

At 13, Elizabeth Hughes, the daughter of the U.S. Secretary of State at the time, Charles Hughes, became one of the first children to be treated with insulin. Although she was fading away at only 45 pounds in 1922 when Dr. Banting began her treatment, she recovered and lived to age 74.

Propelled forward by the milestone discovery of insulin, researchers continued throughout the 20th century to make advances in the quest to control high blood sugar and stave off complications such as heart disease, stroke, kidney disease, and eye problems.  In 1935, physician Roger Hinsworth identified two different types of diabetes, juvenile (Type 1), caused by a malfunctioning pancreas from birth, and adult onset (Type 2), a condition caused by the body’s cells becoming resistant to insulin.

Technical advances improve lives of diabetic patients

Also In the mid-1930s, pork/beef insulin and PZT insulin, a longer acting type, became available. In the 1950s, oral drugs called sulfonylureas for controlling blood sugar for Type 2 diabetes patients were introduced. In the early 1960s, urine test strips were developed to test blood sugar levels. This invention made self-care much simpler for diabetics who had been testing their urine by dissolving a chemical reagent in a test tube and making crude insulin dose calculations based on the chemical reaction. Patients had to wait a week for laboratory blood sugar test results.

In 1969, the first blood glucose meter — weighing three pounds and costing $650 — was developed. In 1979, blood sugar meters for home use became standard. Today, many diabetics wear pager-sized pumps that can be set to administer insulin as needed to control blood sugar.

Incidence of both types of diabetes on the rise

Lollipops are a child's delight but too much sugar can damage a young one's future health. Fotosearch image

The enhanced understanding of the disease and emergence of better treatment tools have happily coalesced to give providers more power to face the barrage of new cases in recent decades. Experts have sounded the alarm that we are in the midst of a diabetes epidemic that will likely get worse.

In 1900, the incidence of diabetes (mostly Type 1) was low; only one or two per 100,000 children in the U.S. were afflicted. Today, the number of diabetics, both Type 1 and Type 2, is growing steadily. Researchers are struggling to understand the increase in Type 1 (up to 14.3 per 100,000), a condition believed to be genetic. The hike in Type 2 diabetes is attributed mainly to an increase in the number of overweight and obese people.

In 2003, the Centers for Disease Control and Prevention researchers reported that the incidence of diabetes in America had increased by 40 percent between 1990 and 1999, from 4.9 percent to 6.9 percent. In the same article in the Journal of the American Medical Association, authors predicted that the number of diabetics would increase 165 percent between 2000 and 2050. In 2011, the American Journal of Managed Care reported the shocking statistic that 25.8 million Americans are suffering from diabetes. That is 8.3 percent of the U.S. population. High and going higher.

KP Care Management Institute addresses diabetes care

Diabetes wordcloud. Fotosearch image

In 1998, the Kaiser Permanente Care Management Institute (CMI) developed the Integrated Diabetes Care Program (IDC) that incorporated the best practices already in use into a uniform, team approach to treating all KP patients with diabetes. New categories of staff were established to specialize in diabetes care; diabetic clinics were set up; and a registry was started to keep track of each patient’s needs and to follow up when necessary.

More than 70 KP experts worked together to develop a comprehensive program that addressed all aspects of diabetes care. These include:  patient education and self-care, long-term control of blood glucose levels, screening for kidney disease, regular examination of the feet for peripheral vascular disease or nerve damage, screening for heart disease, and periodic checks for vision problems.

A tough prescription: Get active and forsake sugar

Research has for the most part verified that a lack of exercise, excessive consumption of sugary snacks and sodas and refined carbohydrates such as white bread, rice, and potatoes, are to blame for the rise in diabetes diagnoses. The challenge for society, medical science and individuals is to reverse this trend. How can we do that?

Kaiser Permanente has been promoting healthy eating and exercise — the prescription for weight loss and prevention of chronic disease such as diabetes — since World War II in the Kaiser Richmond Shipyards. In the late 1960s, a new emphasis was placed on wellness and prevention of chronic disease when KP Northern California opened the first health education center in Oakland. The idea soon caught on in all KP regions, and today a core curriculum is offered in most medical center service areas across the country.

KP’s core Healthy Living courses offered include: healthy lifestyle and weight management, a 10-session program that addresses good nutrition, stress management and physical activity; Weight WatchersTM, a balanced diet program that encourages exercise; Pilates; Personal Health Coach, a program that offers individual support for members to reach their health goals; Fitness for Women 40 and Over; and discounted memberships in community health clubs.

Specifically for members with diabetes or concerns of developing diabetes, KP health education core classes include:  diabetes basics; diabetes foot care; blood glucose meter training, diabetes nutrition, Type 2 diabetes support group, diabetes update, carbohydrate counting for diabetes; prediabetes; insulin pump support group and even a healthy grocery shopping tour for people with diabetes.

Weight of the Nation - HBO series on obesity
Home Box Office series premiers May 14

Kaiser Permanente also offers online Healthy Lifestyles programs that include: CareTM for Diabetes, BalanceTM for weight loss; RelaxTM to reduce stress; NourishTM for healthy eating; BreatheTM to stop smoking; Care for Your HealthTM for managing chronic conditions, including diabetes; and Care for PainTM for chronic pain management. Members can also access SucceedTM a total health assessment that offers advice on how to achieve your health improvement goals.

Kaiser Permanente is one of the sponsors of the Home Box Office (HBO) documentary series the obesity epidemic and its consequences. The four-part series airs on May 14 and 15.