Her father was an internal medicine specialist, and her grandmother Sadie - who in 1906 moved from Belarus to Chicago as a scrawny youngster - developed type II diabetes as she grew overweight. Those were apparently the key reasons why Francine Ratner Kaufman became a pediatric endocrinologist, and eventually one of the world's leading experts on diabetes (especially the autoimmune type I).
Last year, after an amazing career as a clinical physician, author, medical school faculty member and researcher, Prof. Kaufman was named to head the diabetes division at the California-based Medtronic Company, becoming its chief medical officer and vice president for global medical, clinical and health affairs.
Diabetes is a metabolic condition that leads to excessively high levels of sugar in the blood. Chronic exposure of various key organs and tissues - the eyes, blood vessels, kidneys, nerves, feet, heart and gums - to superfluous sugar has several serious consequences. The most reliable way to monitor sugar levels is to test for a type of blood hemoglobin called HbA1C; if the result is higher than 7%, the patient's diabetes is not being properly controlled.
Kaufman recently launched Medtronic's Paradigm Veo interactive insulin pump, which is closer than ever to being the world's first artificial pancreas. For the first time, patients can have a device designed to protect them against severe hypoglycemia even when they're asleep. It automatically shuts off the supply of insulin if a patient's glucose levels drop too low, thus avoiding confusion, a coma and even death. The pump is the first to use data from a sensor that continuously tracks glucose levels to activate an automatic shut-off. It is being marketed here by the Agentek company.
THE FORMER president of the American Diabetes Association, who has been in Israel perhaps a dozen times, was recently here to demonstrate the use of the Veo pump.
She and her husband Neal, a pediatrician, feel at home here, as her father was a "phenomenal supporter of Israel" and relatives from the Vissoker family were early settlers of Petah Tikva, where a street there is named after them. Their sons Adam and Yona, aged 31 and 29, who studied economics and communications, run a startup business together, and came with birthright to get to know Israel.
The annual cost of treating both types of diabetes in the US is $174 billion, said Kaufman in an interview with The Jerusalem Post. The cost is in the billions of shekels in Israel, where there are some 400,000 diagnosed and at least 200,000 not-yet-diagnosed people. Kaufman noted that in her country, there are now one million with type I diabetes, which runs in families and is triggered by some environmental factors, with the person's immune system mistakenly regarding the insulin-producing pancreas as a foreign body and attacking it until it suddenly stops producing insulin to metabolize sugar. Without the hormone, death would quickly result.
FORTUNATELY, the first factory for the production of insulin opened in Denmark in 1925, making it possible to save type I diabetics with regular injections. In identical twins in which one has type I diabetes, there is only a 50-50 chance the second will develop the disease, so there are clearly environmental triggers rather than only genetic ones.
Type I diabetes, prevalent mostly in children and young people ("but I have even diagnosed it in a 72-year-old grandmother," she recalled), is rising in prevalence worldwide at a rate of three percent a year. Although it used to be rare for people under 40 to have type II, the increasing obesity of children that began in the late 1980s has triggered its appearance in youngsters.
In type II diabetes, some insulin-producing beta cells in the pancreas continue to survive, but due to resistance, the body cells do not use the insulin efficiently. It is a lifestyle disease with some genetic influences, and develops gradually, usually without being noticed. Lack of exercise, being overweight, eating a diet of junk food - especially simple carbohydrates - rather than whole grains and vegetables can cause metabolic syndrome (pre-diabetes), which means higher-than-normal blood sugar levels along with high cholesterol and triglyceride levels in the blood, and high blood pressure. If lifestyle changes are not made, this will develop into full-fledged type II diabetes. As symptoms are not always as clear as in type I, people should go for lab tests on a regular basis, especially after the age of 40, or earlier if they are at high risk. Patients are prescribed various oral drugs, such as metformin, that reduce insulin resistance and increase insulin production by the remaining active beta cells. They are also put on a strict diet, ordered to lose weight and placed on a daily exercise regimen. However, researchers are increasingly recommending the use of insulin early on to protect functioning beta cells.
THERE ARE now 23 million type II diabetics in the US, and 44 million are predicted in 25 years, due to the massive obesity rates. Although type II (preventable 80% of the time by changing diet and increasing physical activity) was once thought to affect only wealthy, developed countries, seven out of 10 nations with the largest number of diabetics are countries like China and India in the developing world. By 2025, 80% of all diabetics will live in low- and middle-income countries.
Three decades ago, said Kaufman (who invented a tasty snack named ExtendBar to help diabetics cope with a sudden attack of low blood sugar), there was almost no type II in US children, but due to overweight and obese kids, a quarter of new cases are in fact youngsters. Kaufman noted that Europeans, including Jews of European origin, apparently have a set of genes that make type I and type II more common among them. Infrequently, a person can have both types.
Stress does not cause diabetes, "but when there was an earthquake in California, we had a huge increase of children diagnosed with type I. Then there was a lull. I think they would have developed it anyway, but the stress caused it to appear earlier."
For most of human history, she said, starvation was the biggest peril. Then came "progress" with domestication of animals, refrigeration and energy-saving devices. But by the mid-1970s, enough calories were produced for everybody - although they were badly distributed, so many were undernourished. Since then, many countries have too much to eat, leading to obesity. "Now we have to redefine progress and put people in the right energy balance," she said, noting that the desk in her office is built with a treadmill surrounding it.
Peoples who were better adapted to starvation, such as the Aborigines in Australia, American Indians or blacks brought as slaves to America, were more likely to develop type II diabetes when plenty of food - especially sweet, starchy and fat food - became available. The same, she suggests, has occurred among Jews from Ethiopia, in whom diabetes was almost unknown.
Being overweight or obesity was long regarded with envy because most people couldn't get enough food to become plump. One need only look at classical paintings, in which fat women were the ideal. Today, most Americans know it is dangerous to be fat, she said. While Israelis are certainly not as overweight as Americans, Kaufman said, "they are on their way. I see so much junk food eaten here, and I'm not convinced that Israelis are getting enough exercise. Obesity is increasing even in France, Sweden, England and Asia where it was not common before."
Despite the rampant obesity in the US, Kaufman said a very serious campaign against it has been launched around the country. "Twenty years ago, we were told we shouldn't smoke, and today most don't. Today we know we should not be obese, and in the coming years, more will learn to avoid it."
In California and other states, soft drinks have been banned from schools due to a healthful vending machine policy. School cafeterias have stopped serving food with corn syrup and introduced more fruits and vegetables. But there are still no limits on advertising for kids' TV programs. "There are signs that growth in US obesity rates among children and women is flattening out. They might even be decreasing," Kaufman said, "but not among men."
It has already become a social norm not to keep a lot of candy around the house, added the endocrinologist, who for years was a pediatrician at the University of Southern California and worked at the Center for Diabetes, Endocrinology and Metabolism at Children's Hospital in Los Angeles, where she continues to live.
KAUFMAN, who has conducted much research in intensive management of type I diabetes and its prevention in children and youth, is very enthusiastic about her company's insulin pumps. Some families buy them themselves, while others get subsidies. They have revolutionized the treatment of young children with type I diabetes, she stressed, as it is very difficult to balance insulin injection and meals in them. The new Veo pump works somewhat like an automatic defibrillator. Diabetics often had to wake up in the middle of the night to test their blood sugar manually, and now this will be unnecessary.
Today, the only way to cure type I diabetes is with a pancreas transplant, which is very hard to get and requires immunosuppression drugs which can be "worse than diabetes itself, as the recipient can be susceptible to pathogens." It could be cured if beta cells are transplanted in a way that they produce insulin without being attacked by the immune system, she said. Type II could also become much easier with improved medications. "I came to Medtronic because I felt that an insulin pump that is nearly an artificial pancreas [except that it needs some human input during meals] would be a great advance. If the wearer has low blood sugar and doesn't respond to an alarm informing him of this, the pump will stop insulin delivery automatically. You fill the insulin reservoir only every three days, and don't feel any injection because the needle is attached to the body. You can even shower with it, as the catheter stays in," says Kaufman, who is known to the public from her book Diabesity and a Discovery Channel TV show on diabetes that she hosted.
Coming to Israel again and meeting with endocrinologists was a pleasure, she concluded, as Israelis "lead the world in this field. They are phenomenal scientists and investigators and work collaboratively, showing a lot of leadership. Israelis are very valued contributors to our business."