A patient with diabetes consults with U health care providers.
Across the University, the battle has been joined against the debilitating disease
By Deane Morrison
From M, summer 2006
EDITOR'S NOTE: The University is one of the leading diabetes research and treatment centers in the world. In the following article, Deane Morrison explores the three types of diabetes and possible means of preventing this debilitating and increasingly common disease. For information on clinical trials and surgical options for people with diabetes, see All our trials.
When he came in for help last year, the man had already lost his kidneys and his sight to diabetes. A kidney transplant had saved his life, but with his blood sugar hovering around 300--close to three times the normal level--it was only a matter of time before the disease destroyed his transplanted kidney. "He never understood the importance of carbohydrate, or 'carb,' counting and basing his insulin injections on his carb intake," says nurse educator Adele West, coordinator of the Diabetes Care outpatient program of the University of Minnesota Medical Center, Fairview. West and her staff of nurses and dietitians worked with the man, teaching him how to monitor and manage his blood sugar, which has now dropped to around 130. "If he hadn't improved, he would have needed a second transplant," says West. By calling on expertise from all of its campuses, the University has become one of the nation's leading centers in diabetes care and research. From helping people with the day-to-day management of diabetes to running the nation's largest pancreas transplant program, the University is waging a multipronged assault on a disease that affects about one in 17 Americans. Prominent among its victims are the poor; people of American Indian, Asian, black, and Hispanic descent; and increasingly, children. The World Health Organization estimates that more than 175 million people worldwide have diabetes, with 300 million cases projected by 2025.
Three types of diabetes
Diabetes is really several diseases--type 1, type 2, and gestational diabetes--that involve the hormone insulin and its ability to control blood sugar. Insulin is pumped into the blood by beta cells, which, along with other cells, are found in the pancreas in scattered bundles called islets. In healthy people, insulin enters cells in the liver, muscles, and other organs and directs them to take up fatty substances and the sugar glucose from the blood, maintaining a healthy balance. In type 1 diabetes, the immune system attacks and destroys the body's own beta cells, limiting their ability to produce insulin to protect against excess blood sugar. Genetic factors may predispose people to contracting the type 1, but environmental factors also play a large role. An identical twin of a person with type 1 diabetes has about a 30 percent chance of also developing the disease; this is much higher than the 1-in-200 or so chance of the general public but still less than the near-100 percent chance one would expect in an identical twin if genetics alone were the cause. Evidence suggests that the disease arises when one or more viral infections trigger a response from the immune system that leads to the destruction of beta cells. In type 2, the major problem is that cells can't respond to insulin--a condition called insulin insensitivity. Type 2 is associated with obesity, and it accounts for at least 90 percent of diabetes cases. Often in obesity, fat storage cells become glutted, and this leads to the production of protein molecules that signal the cell to stop responding to insulin. When they do, the fat cells close the door on circulating fats and glucose, which now migrate into the heart, liver, muscles and other organs. When these organs--especially the liver--fill up with fat and stop responding to insulin, fats and glucose have nowhere to go and so build up in the blood. "The resistance to insulin is reversible, especially in the early stages," says David Bernlohr, head of the biochemistry, molecular biology and biophysics department. But there is no reversal for many people who cannot change their diet and lifestyle. "It's clear the American public is consuming more calories than they did decades ago," says Bernlohr. "Compounding it is less exercise and active work." In the third type of diabetes, gestational diabetes, a pregnant woman cannot produce enough insulin to control her and the baby's blood sugar. It usually disappears after childbirth, but it can cause complications such as high birth weight, and it is important that it be controlled.
A young people's disease
Prolonged high blood sugar levels cause numerous complications, including kidney failure, blindness, and damage to nerves and blood vessels that may necessitate limb amputation. Such nightmares already visit many people after 15, 20 years or more of uncontrolled diabetes. But these days, it is clear that type 2 diabetes, once unheard of in adolescents, is striking them in alarming numbers. Children are increasingly engulfed in a culture of pizza, doughnuts, supersized soft drinks and other treats, with gym classes cut to once a week--or eliminated altogether--all things that can contribute to type 2 diabetes.. Type 2 diabetes is hard to diagnose in children, but it is clear that the disease, once unheard--of in adolescents, is striking them in alarming numbers. It's bad enough to lose a leg or a kidney at age 60, but when diabetes gets such an early hold it means many will face such consequences at age 35. This pattern is already putting pressure on the health care system.
Along with helping to graduate Native American health professionals, Woodlands Wisdom supports healthy food and healthy lives by delivering two tons of organic produce each year to Native American food shelves and diabetes education groups.
The rise coincides with the American obesity epidemic, whose first signs appeared about two decades ago. That was close to the time when cable TV, video games and the couch potato syndrome appeared. Another contributing factor is the relatively recent practice of replacing cane sugar with a cheaper sweetener--high--fructose corn syrup--that allowed soft drinks to be supersized for the same cost. This ingredient also appears in items from hamburger buns to cough suppressants. "Much of the fructose consumed goes into the liver," says Bernlohr. "The excess fructose is converted to triglycerides [fat], which go to muscles and fat cells [and impede the function of insulin]. All the experts give the same advice on staving off type 2 diabetes: Eat better and exercise. Walk as much as possible. Take the stairs instead of the elevator, get off the bus a few blocks early, get out of the house or office once a day. The idea is to burn off all the calories you eat. The wisdom of a traditional diet
Some of the hardest--hit by type 2 diabetes are American Indians, who in the last century have been forced to abandon traditional foods and active lifestyles for a regimen of high--caloric Western food and little opportunity for historically important exercise like farming, gathering, hunting, or herding. Food science and nutrition associate professor Craig Hassel illustrates this with the tale of the Pima Indians of Arizona and Mexico.
The University of Minnesota Medical Center, Fairview, provides inpatient and outpatient diabetes education and self-management programs. For inpatient services, call (612) 273-4894. For outpatient services for adults, call (612) 626-1123; for children, call (612) 626-6777."In Arizona, they would grow subsistence crops after seasonal flooding of rivers," says Hassel. "But around 1911 the Roosevelt Dam--and others--were built, and it dried up the rivers downstream. They started relying on the government, including government surplus food. Three generations later, they have the highest rate of diabetes in the world, around 50 percent. The Mexican Pima haven't had their rivers dammed, and their rates are much lower." The Pima of Arizona's Tohono O'odham Reservation have begun a community food project to replace government surplus, which has lots of calories and isn't as nourishing as Indian food, Hassel says. At the University, he is part of an organization with similar goals. Woodlands Wisdom, a collaboration between tribal colleges and the U, seeks to graduate American Indian health professionals who will return to their communities and foster a resurgence of more traditional diets--including fish, game meats, berries, wild rice, and garden vegetables--and lifestyles. Its success rests on its ability to apply scientific knowledge to augment, rather than replace, the expertise of woodlands people. A hearty endorsement for this kind of collaboration comes from Macaran Baird, head of the family medicine and community health department. "We [the University] will never have enough resources to deliver health care on our own," he says. The academic model--one--way delivery of health care from professionals to patients--must change, especially with problems like type 2 diabetes, which are so steeped in cultural practices, says Baird. To that end, he is building a new model with colleagues like Tai Mendenhall of his own department, Bill Doherty from family social science, and Jim Hart from public health. Called Citizen Health Care, the project--in--planning will make patients from as many communities as possible, including American Indian, black, Hmong, Hispanic and Somali, part of health--care teams. The U's diabetes treatment, research, and prevention efforts illustrate what a research university is all about. Working for, and with, people to help make their lives better is the greatest contribution the University can make.
For a companion article on clinical trials and surgical options for people with diabetes, see All our trials.