Why Does It Happen?
Diabetes has been known since ancient times—the word, from the Greek, means “siphon,” an allusion to the fact that body fluids seemed to flow from diabetics through frequent urination. The disease’s full name is diabetes mellitus, the latter word being Latin for “honey-sweet,” added in 1674 by the physician to King Charles II, who noticed that a diabetic’s urine often was sweet. Lots of remedies were suggested—from opium and bleeding to diets of dates and gruel—but nearly all diabetics died an early death.
Medicine has understood since the 1890s that diabetics’ bodies don’t handle insulin properly. This essential hormone—secreted by the pancreas and released after a meal when glucose increases in the blood—normally stimulates muscle and fat cells to remove the glucose and the liver to metabolize it, causing blood sugar to decrease to a normal level. In diabetics, the pancreas either produces little or no insulin or the insulin produced isn’t properly utilized.
Type I diabetes—the type that Sonia Sotomayor has—usually is diagnosed in children and adolescents and was once known as juvenile diabetes, a term now deemed inappropriate because many Type I diabetics live into adulthood. It’s an autoimmune disease in which the body attacks and destroys cells in the pancreas, leaving a person with no natural insulin supply. To survive, Type I diabetics must get daily insulin injections for the rest of their lives. Of the two main types of diabetes, Type I is much less common, affecting one in every 600 American children—about 180,000 in all.
The more common Type II diabetes affects nearly 24 million Americans—it’s the kind that’s increasing so rapidly. It usually is diagnosed in adults and was once known as adult-onset diabetes; that term is now inappropriate in part because of the disease’s increasing incidence among the young. In Type II diabetics, the pancreas produces insulin, but the body doesn’t utilize it in a way that keeps blood-sugar levels normal. Some women develop a variation called gestational diabetes during pregnancy.
Another twist is pre-diabetes, which has come to be recognized as a warning sign. Pre-diabetics are people whose blood sugar is elevated enough to signal that they may be on the road to Type II diabetes unless they take steps to get their levels back to normal. There are a couple of blood tests for pre-diabetes, and experts believe that the number who suffer from it is very large, perhaps as many as 57 million Americans.
Scientists haven’t yet pinned down how much diabetes is determined by hereditary factors and how much by behavior. Both types have a genetic component, but Type II seems to be triggered by an unhealthy lifestyle, especially obesity and lack of exercise. Children of two parents with Type I diabetes are more likely to have it.
From Head to Toe
Diabetes not properly controlled can trigger an avalanche of complications. Experts agree that its actual death rate is underestimated because doctors who fill out death certificates and writers who draft obituaries report the complications rather than the underlying disease. The breakdowns a diabetic can suffer run from head to toe.
Starting with the head, chronic exposure of fragile blood vessels in the eye to high blood sugar causes damage that can lead to blindness. The condition, known as diabetic retinopathy, causes up to 24,000 new cases of blindness each year, making diabetes the leading cause of blindness in adults. Jackie Robinson, a Type I diabetic who broke baseball’s color line in 1947, was blind when he died at age 53.
Periodontal disease, which affects the gums, affects about a third of diabetics.
Diabetes is associated with deadlier complications surrounding the body’s cardiovascular system, where it can be connected with high cholesterol, high blood pressure, and damage to blood vessels leading to strokes and heart attacks, which account for 65 percent of deaths among diabetics.
Diabetes is the leading cause of kidney failure, accounting for nearly half of new cases each year. Many of the 180,000 Americans on kidney dialysis are diabetics; some of those facing renal failure—such as former DC mayor Marion Barry—end up with a kidney transplant.
Farther south, erectile dysfunction—a complicated problem that can result from nerve damage and inadequate blood flow—is experienced by 35 to 50 percent of men with diabetes. And diabetics over age 60 are two to three times more likely to be unable to climb stairs.
Diabetes causes nerve damage that can lead to amputation of lower limbs and appendages—about 71,000 amputations a year in the United States. This damage can express itself as a tingling or loss of feeling in toes, feet, or legs—the medical term is peripheral neuropathy—and it can be so severe that diabetics can’t feel the ground when they walk. The worst scenario begins when a blister, ulceration, or cut goes unfelt and untreated, high blood sugar interferes with healing, infection sets in, gangrene develops, and amputation is required. This is why diabetics are advised to check their feet daily for blisters, cuts, or sores.
Along with blindness, amputation is the most poignant consequence of diabetes. Jackie Robinson lost a leg to the disease, as did jazz singer Ella Fitzgerald, and amputations were the fate of several prominent diabetic Washingtonians, including singer Shirley Horn and columnist Carl Rowan.
Political columnist David Broder told his own story of the dangers of diabetes a few weeks ago at a medical conference organized by Georgetown University Hospital, home to one of the country’s leading programs trying to spare diabetics from amputations. While covering the Iowa presidential caucuses in 2000, Broder says, he did “something really stupid.” He got a sore between the toes of his left foot, neglected it, and let it become infected.
“I didn’t want to shut down and leave the campaign trail, so decided to tough it out,” he told conferees. After a week or so, the pain was severe enough that he went to a clinic in Des Moines and was sent to a hospital and put on antibiotics.
When the caucuses were over, Broder went to see Christopher Attinger, his doctor at Georgetown: “He gave me hell, as he should have, then began to make the best of a bad situation.” To save Broder’s feet, Dr. Attinger removed all of the toes on the left foot and the big toe on the right. Broder has had no problems with his feet since then, though he uses orthotic shoes.
All of this reminds me of my father, who spent his life in Missouri raising cattle and was diagnosed with diabetes in his mid-fifties. He wasn’t aggressive in controlling it—he took a few pills but kept eating coconut-cream pie and putting on weight. By his mid-seventies, he was in a nursing home; a few years later, he’d lost his right leg, all the sight in his left eye, and most of it in the right.
When I flew home to visit, I had to get the nurses to help me hoist him into his old Chevy pickup, and he no longer could jump out and open the gates when we went out to see his cattle. I don’t think he could see his cows very well, though he pretended to. Mostly he stayed in the pickup dropping cigarette ashes on his overalls.
One of his last remaining joys was the Baby Ruth candy bar an old buddy sneaked into the nursing home every week. He’d try to eat it quickly before he was caught, his friend keeping a lookout. Finally, one warm spring night when he was 84, he lapsed into a coma and died.
I was lucky to be there, but I always figured that Dad’s diabetes might be a bad omen for me. So it wasn’t a big surprise when in my mid-fifties my doctor said diabetes had caught up with me.