Diabetics' New Gospel of Control

By Claudia Wallis

Frequent blood tests can help sufferers lead a normal life

It is the first day of class. Five students sit expectantly around a table that nearly fills the small, brightly lit room. They are an attractive group: educated, well-dressed, ranging in age from 27 to 35 and seemingly healthy. Yet most of their lives they have been suffering from a life-threatening ailment: diabetes, which ranks behind only heart disease and cancer as a cause of death in the U.S. Some of those in the class have begun to experience the terrible complications associated with the condition. Jim, a diabetic for 20 of his 27 years, has begun to lose his eyesight and kidney function and has early signs of heart disease. Bob, 35, has had so much laser surgery to preserve his failing eyesight that he worries about losing his peripheral vision.

The diabetics have enrolled in a five-day course at Manhattan's Diabetes Self-Care Program (D.S.C.P.) to learn how to manage their disease better. Two of the women have another goal: they hope to become pregnant and would like to improve their chances of bearing healthy children. What they are about to learn will radically alter the way they live. Says Dr. Lois Jovanovic, their instructor: "We're going to revamp you, soup to nuts."

Over the past ten years, the treatment of insulin-dependent, or Type I,* diabetes has undergone a quiet revolution. D.S.C.P. is one of several programs that have sprung up around the country to spread the gospel of this movement. Its watchword is tight control, or keeping a close rein on the disease so that the body can function as normally as possible at all times. In practice, this means a lot of hard work.

Like most Type I diabetics, the students entering the self-care program are accustomed to giving themselves one or two daily shots of, insulin, the hormone that their pancreas is unable to produce naturally. Insulin is essential for the metabolism of glucose, the simple sugar that serves as the body's principal fuel. Without an adequate supply of insulin, glucose literally goes to waste, passing out of the body in the urine so that the individual slowly wastes away.

Diabetics have traditionally assessed their need for insulin by testing the amount of sugar in their urine, using a simple chemical test. Unfortunately, this test is unreliable, and Type 1 diabetics generally suffer from abnormally high and often wildly fluctuating levels of glucose in their bodies. It is suspected that many of the complications of the disease--blindness, kidney failure, narrowing of the arteries and gangrene leading to amputation of limbs--are caused by the buildup of sugar.

The tight-control movement aims to avoid these problems by keeping sugar levels within normal bounds. The only way to do this is by constantly monitoring the level of glucose in the blood. At programs like D.S.C.P., diabetics learn to perform the procedure at home, using special strips of chemically treated paper. When a drop of blood is placed on the strip, the paper changes color. The shade indicates how much glucose is present in the blood, and can be interpreted by either matching it to a color chart or feeding the strip into a small electronic device.

Students are taught to test their blood four or five times a day. Their goal: to remain within the "gray zone," the normal range of readings between 50 and 150 mg of glucose per 0.1 liter of blood. The adjustment is uncomfortable for those whose bodies are used to higher sugar levels. "I usually feel more energetic at around 200," says Angela, 28, but she is happy to make the change because studies show that this discipline will improve her chances of having a normal child.

Less certain is whether tight control can prevent or arrest the life-threatening complications of diabetes. But, says Dr. Charles Peterson, director of D.S.C.P., "we believe there's enough evidence to tell patients it will give them the best chance of maintaining good health."

To stay in the gray zone, Angela and her classmates will have to increase their injections of insulin from two a day to three, and in some cases four, usually taken before meals and at bedtime. By far the most difficult part of the tight-control regimen is learning how much insulin to give. Most diabetics are accustomed to simply following doctors' orders when it comes to their dosages. Not so under tight control. Students in the self-care program must learn how to adjust their insulin dosage based on their last blood-glucose reading, what and how much they plan to eat, how much they are exercising and whether they are under stress. Regular aerobic exercise, they learn, can lower the need for insulin. Stress, on the other hand, "can raise blood sugars higher than an ice cream sundae," says Dr. Jovanovic, who is herself a diabetic.

Barbara Turro, a nutritionist, teaches the students how to manipulate their blood sugar by varying their diet. Food rich in protein, she points out, causes blood sugar to peak about three hours after it is eaten; carbohydrates produce a much swifter rise. When blood-sugar levels are too low, producing a weak and dizzy state called hypoglycemia, Turro recommends drinking milk, which contains carbohydrates to produce a quick rise and protein to sustain it.

By week's end all of the members of the class have successfully entered the gray zone. Two have achieved and maintained this state with the help of an insulin pump, a still-experimental device that mechanically injects a maintenance dose of insulin into the body throughout the day. For all the demands and nuisance of the tight-control regimen, most graduates say it has given them greater freedom. Instead of being told they must never eat ice cream or alter their meal times, they can be more flexible and occasionally enjoy forbidden foods, as long as they adjust their insulin accordingly. Says Bob: "I now have the tools to live the life I want to lead." --By Claudia Wallis. Reported by Mary Carpenter/New York

* Type II diabetes is associated with obesity and can often be controlled by diet alone.

With reporting by Mary Carpenter/New York This file is automatically generated by a robot program, so viewer discretion is required.