Every 10 seconds, someone dies of a diabetes-related illness. In the run-up to World Diabetes Day on November 14, what can be done to improve the situation both in Israel and worldwide?
The life of a diabetic is one of constant self-monitoring. Those diagnosed with the disease describe it as an endless attempt to keep track of their weight, food intake and blood sugar levels and keep them in balance. For those who are successful, the abyss of ill health always lies beneath and poses a constant threat. For those less successful, climbing up from the bottom to the surface is a challenging and sometimes prohibitive task.
The patient usually knows the rules, at least after he is diagnosed and instructed on how to live with the chronic disease. In the developing world, where medical facilities are few and far between and there is no money to buy drugs - even insulin - or time and means to change lifestyles, the patient moves as if on a downward sloping conveyor belt toward what is almost inevitable disability, pain and death. There are more people in the Third World whose legs have been amputated due to complications of diabetes (reduced blood flow and harm to nerves in the feet can lead to foot ulcers and gangrene) than those who have lost them from land mines.
But even in Western countries, balancing sugar levels can be a struggle. There is usually no one around to constantly tell the patient what to do. The diabetic must unceasingly be his own policeman, pushing himself to exercise even when he is tired, puncturing his fingers for a drop of blood to test for sugar, eschewing enticing desserts when everyone else is enjoying them, going for medical checkups when he'd rather avoid them, taking medications and injecting insulin several times a day if necessary.
To increase awareness of the disease and push for prevention, early detection and treatment, the World Health Organization (WHO) and International Diabetes Federation established November 14 as World Diabetes Day, which is being marked in Israel and around the globe.
Every 10 seconds, someone in the world dies of a diabetes-related illness. Diabetes is the fourth leading cause of death by disease. Diabetic retinopathy, in which the small vessels in the retina are gradually damaged by high sugar levels, is an important cause of blindness; after 15 years of diabetes, about two percent of patients lose their sight, and an additional 10% develop severe visual impairment. Diabetic neuropathy, whose symptoms are tingling, pain, numbness or weakness in the feet and hands caused by damage to the nerves, affects up to half of diabetics. Diabetes is among the leading causes of kidney failure, with 10 percent to 20% of diabetics dying from it. Diabetes increases the risk of heart disease and stroke: Half of diabetics will die of these two threats.
Is it any wonder that diabetics - both of the autoimmune Type 1 and the lifestyle disease of Type 2 - are at significantly higher risk than non-diabetics to develop clinical depression?
Representing Israel at the Novo Nordisk Media Prize competition in Copenhagen two months ago, I met numerous diabetics of all ages who were invited to tell their life stories. From the way they spoke, I could quite easily sort out those holding their own from those who were engaged in an uphill struggle.
Gerda, a 66-year-old Danish woman who was diagnosed with Type 2 as a young adult, seemed to belong to the second group.
"I was a bank clerk and interpreter for the hearing disabled - a skill I acquired at home, as both my parents were deaf. I was responsible for them even as a small girl. I served as their ambassador. I made up for my lost childhood by eating. Suddenly at 30, I was very tired and thirsty," said Gerda, who is so obese that she has difficulty moving even with a metal crutch.
"After three weeks in the hospital, I was told what I had - 'the old man's diseaseâ€š' even though I was not a man and I wasn't old. I tried to lose weight, but I was unsuccessful. Although I loved to travel and dance, by 1984 I developed complications. I suffered from neuropathy and had accidents. I went barefoot at home one day and a glass broke; I stepped on it, but I wasn't aware that my foot was cut, and it didn't heal."
She developed sores, and eventually, some of her toes were surgically removed. "My whole world had broken down. I got no psychological help. Today, I can't lose weight because I can't exercise."
Living alone on a pension, Gerda admitted that she is still angry for "sacrificing her childhood" for her parents, overeating to obesity and then developing diabetes. "I paid a high price, but I can't blame them. It's my problem."
She spends most of her time at home, saying she has never thought about going to a swimming pool designed for the disabled to get the only type of exercise she can. "In any case, I don't have a car, and it would be hard to get there," she shrugs.
But Alex, a 20-year-old Australian diagnosed with Type 1 diabetes at the age of three who now lives in Belgium with his girlfriend, seems unwilling to forgo any of life's pleasures and challenges.
"My mother came with me on school outings to make sure I got my insulin, and I had a great time. At 15, I won the national sailing championships and later I joined the Australian Olympics sailing team. I'm proud to treat my diabetes by myself," says Alex, a tall and thin but muscular young man.
"I don't have many worries. The fear of a hypoglycemia episode [in which blood sugar drops dangerously] is always at the back of my mind, but I can usually feel the early symptoms, and I take care of it. I am very determined. I learned not to give up, and I take good care of myself."
He noted that testing equipment available now is very convenient. Years ago, he said, diabetics had to boil a urine sample with a tablet to watch the color change and see how high the sugar was. Today, there are glucometers and no guesswork. Insulins come in more forms and are easier to take.
Ib, a 74-year-old Danish retired company manager, is - like Alex - looking into the light.
"I was diagnosed 14 years ago, and I thought it was unfair that it happened to me. There was too little understanding then of what it was to be Type 2; now there are many more, so it is accepted. I remember that when on an airline flight, the stewardess would call out: 'Who is it who ordered the diabetic meal?' Today, people are more discreet. Still, I kept my condition to myself. I have a perfect life. One can be diabetic and live well," he declared.
WHILE DIABETES can put a heavy burden on the individual, the disorder threatens to cause health systems around the world - in the developing world as well as the industrialized nations - to collapse. In one generation, the prevalence of diabetes has already increased six-fold worldwide due to obesity, poor diet, lack of exercise and longer life expectancies. There are some 230 million diabetics today (about 400,000 in Israel), about two-thirds of them not meeting their optimal sugar level targets, and their ranks are expected to increase by 2030 to 366 million.
Type 1 diabetes, diagnosed mostly in young people, 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 2, increasing obesity in children that began in the late 1980s has triggered its appearance in youngsters. Type 2 has become one of the leading chronic diseases in childhood and adolescence, according to epidemiologists, with a prevalence of 1.82 per thousand compared to 1.24 per thousand for cancer.
Although Type 2 (preventable in 80% of cases by changing diet, increasing physical activity and improving the living environment) has an image of affecting only wealthy, developed countries, seven out of 10 countries with the largest number of people living with diabetes are nations like China and India (which today has 35 million diabetics compared to 19 million in the US) in the developing world. By 2025, 80% of all diabetics will live in low and middle-income countries.
Today, direct healthcare expenditures for diabetes-related illnesses is estimated at between $153 billion to $286 billion. If the predicted increase in diabetes pans out, this will jump to an astronomical $396 billion a year, also by 2030, paralyzing health systems. And diabetes is already one of the most expensive health problems in the world.
According to the WHO, direct healthcare costs of diabetes-related illnesses range from 2.5% to 15% of a country's annual healthcare budget, depending on local diabetes prevalence and the sophistication of treatment available. This could rise to 40% in high-prevalence countries.
Direct costs in medications, hospitalization and equipment to cope with blindness, kidney failure, nerve diseases, limb amputations and cardiovascular diseases are only part of the story. There are also indirect costs such as lost productivity due to the inability to work, sickness, absence, disability, early retirement and premature death.
While these are more difficult to calculate and predict, cost estimates for 25 Latin American countries suggest that lost production due to diabetes may total as much as five times the direct cost of treatment. Families, too, suffer loss of earnings when a breadwinner comes down with the disease.
One must also consider the financial burden of caregiving for people in nursing homes and their own homes who are disabled from complications due to mismanaged diabetes, plus special transport and appliance costs. In Denmark, these are estimated to comprise 76% of the total cost of diabetes.
Increasingly distressed by the looming pandemic, the International Diabetes Federation has initiated a global campaign for persuading the UN to pass a resolution on diabetes before next year's World Diabetes Day. Newly elected federation president Prof. Martin Silink (an endocrinologist from Australia) said at a press conference in Copenhagen in mid-September that UN member states must take action against the disease, making AIDS, tuberculosis and malaria look like minor problems in comparison.
The federation, backed by Danish-based pharmaceutical company Novo Nordisk, fears that unless the disease is prevented and diagnosed early to head off devastating and expensive complications, health systems everywhere will collapse under the burden.
He said the idea for a UN resolution, first suggested to him by a 16-year-old girl named Claire Rosenfeld, initially raised skepticism. But the federation and Novo Nordisk got on the bandwagon and were optimistic that the UN could be prodded into action. The UN General Assembly had previously passed a resolution for the fight against HIV/AIDS. Silink said that although a resolution by the 192-member UN body would be voluntary, he hoped it would be followed by an obligatory decision by the Security Council.
After the press conference, Novo Nordisk, the world's leading diabetes care firm, displayed its 26-ton "Changing Diabetes" bus, a seven-meter-long vehicle that has already begun to visit 12 countries (not including Israel) on five continents before World Diabetes Day in 2007. It is planned to visit parliaments, schools, hospitals, pharmacies, convention centers and town squares, with the aim of educating laymen, decisionmakers and children about diabetes.
Inside the vehicle, whose sides are collapsible to allow it to travel through the streets, are video screens explaining the disease, blood sugar testing equipment, a computer console with educational games for children and tape measures for measuring waists (abdominal fat is a risk factor for Type 2 diabetes).
A global Task Force with representatives from patient groups, primary care, nursing and diabetologists who discuss how to improve diabetes control has been established by the non-governmental International Diabetes Federation (an alliance of some 190 national diabetes associations, including Israel's, which is headed by Dr. Julio Wainstein) and the Danish company, which has also launched a drawing contest for children to express their feelings about living with the disease. In addition, it has pioneered a patient-empowering initiative of consulting with large numbers of diabetics about their psychosocial and treatment needs.
WHAT IS ISRAEL'S health establishment doing to cope with these challenges? It is doing something, but not enough, conceded Health Ministry associate director-general Dr. Boaz Lev.
"We established the program in which health funds must report on how many of their members are treated properly for chronic diseases such as diabetes. The insurers, at their own volition because it is to their financial benefit, have launched health promotion campaigns to promote physical activity, proper diet and disease screening, and our Israel 2020 program is currently preparing plans for reducing disease and promoting health over the next 13 years."
But ministry money has not been allocated specifically to prevent diabetes and minimize complications, said Lev.
"We act not only with allocations but also with legislation and information, and we encourage the health funds to promote health. In due time, we hope to see that all Israelis are screened and targeted for the prevention and early diagnosis of diabetes. We are concerned about the future costs, but we are not in a worse situation than other countries."
As for including new diabetes medications in the basket of health services, Lev said the decision would be taken after cost-benefit analyses are completed and the public committee on expanding the basket is instructed to meet.
Although the government has not taken specific action to battle diabetes, Israel's medical researchers and friends in the US have. Two years ago, a major program to turn Israel into one of the world's leading centers for the treatment and cure of diabetes was launched. Called D-Cure, it was aimed at tripling the current level of research funding for the disease and coordinating the efforts of medical and scientific research centers around the country.
Today, D-Cure president Prof. Itamar Raz is very excited about the results so far. "We have created cooperation and collaboration among the major research centers here such as the Weizmann Institute, Technion, Hadassah University Medical Center, Ben-Gurion University and the Hebrew University, with research to be done by veteran diabetes researchers as well as scientists from other disciplines who were drawn to diabetes research by D-Cure's activities, in a major collaborative effort with the Juvenile Diabetes Research Foundation."
So far, nearly two-dozen impressive research proposals were presented, and three outstanding projects were chosen by independent reviewers in the US. Several specific researchers were also selected to do work. The grants, whose subjects include research on beta cell replacement for both types of diabetes and prevention of beta cell death in Type 1 diabetes, total $500,00 to $600,000 annually for two or three years.
In addition, D-Cure has enlisted cooperation with the Einstein College of Medicine and Columbia University in New York, which will hold annual meetings. In the future, D-Cure hopes to fund fellowship grants in the US for promising young Israeli diabetes researchers.
Among the possible avenues toward prevention and cure of diabetes are gene therapy (which has already reversed Type 2 in mice), a diabetes vaccine, improved oral medications and using human stem cells to turn liver cells into insulin-producers for transplant into the body.
"Diabetes needs a unification of forces to wipe it out, and we believe a cure will be developed in the next decade," Raz concluded. "Despite Israel's small size, it can turn into one of the world's leading centers with interdisciplinary cooperation among the researchers here and abroad and a significant increase in funding, and this is what we are doing."
The oral consequences
Although dental treatment was not included in Israel's National Health Insurance Law and is thus not in the basket of health services provided by your health insurer, what is happening in your mouth has a direct connection to diseases in the rest of your body.
Periodontal disease - chronic inflammation of the gums found to some extent in the majority of adults - was thought for years to be a problem limited to the oral cavity. But in recent years, evidence has been mounting that this chronic condition affects the systemic health of the individual.
Caused by pathogenic bacteria found in the mouth that colonize the plaque surrounding the teeth, such inflammation is responsible for most cases of tooth loss in adults over the age of 30. The disease develops slowly and is usually without symptoms, which means patients will be diagnosed long after the process begins. The typical clinical warning signs are red and swollen gums with bleeding, especially after brushing the teeth.
Studies in animals and humans have clearly shown that there is an associative and causative link between periodontal infections and low-birth-weight babies. In addition, men younger than 50 who have gum disease are at a significantly higher risk of developing heart disease than counterparts who have healthy gums. So far, there is no research showing that atherosclerosis (clogging of the coronary arteries) can be prevented by treating gum disease, but many studies nevertheless show a connection between the two. Research has also linked the debilitating autoimmune disease multiple sclerosis with gum disease.
To try to understand the mechanism that links periodontal disease with systemic disorders, researchers at Hebrew University-Hadassah Medical School and Dental School are studying the connection between oral bacteria and changes in the function of the immune system, with a focus on molecular changes caused by the immune system's chronic exposure to periodontal bacteria. These microorganisms adhere to the roots of the teeth, swell the gums and remain there for 30 years or more; they enter the bloodstream and are bound to affect the rest of the body, not just the mouth.
The mechanism by which they cause trouble in the rest of the body is not very clear, but diabetes researchers believe the bacteria spread via the bloodstream, increase insulin resistance and thus raise the blood sugar level. This not only makes it difficult for diabetics to balance their blood sugar levels; it can also increase the risk for developing Type 2 diabetes.
A State University of New York study of diabetic patients showed that treating their gum disease significantly reduced their blood sugar levels and the need to take drugs for their condition. Thus, one of the first things that a newly diagnosed diabetic should do is go to the dentist and get periodontal treatment if necessary.
Studies carried out among pregnant women who have gum infections showed that treating their gum disease helps prevent gestational diabetes, which is the inability to process dietary sugars normally during pregnancy and puts women and their babies at increased risk of injury and illness. This temporary condition can increase women's risk of later contracting Type 2 diabetes.
Nearly half of all pregnant women with gestational diabetes also have periodontal disease, compared to one in 10 pregnant women without gestational diabetes, according to researchers at Tulane University in Louisiana. The recent study, published in the American Journal of Obstetrics and Gynecology, was the first to demonstrate a link between poor oral health and diabetes during pregnancy. Based on their analysis, the researchers recommend that dental care during pregnancy be considered as a way to help prevent gestational diabetes.
Any form of diabetes will influence one's gums, and even well-controlled diabetes will cause some negative changes in the periodontal condition. Therefore, all pregnant women should have several dental exams, preferably one before the start of pregnancy, another at three months (without x-rays), a third three months later and a fourth six weeks after delivery, and all diabetics should visit their dentist every four months.