Diabetes, Our Modern World and Katrina

Last weekend I spent hours on the phone trying to help assure that people with diabetes would be cared for in the aftermath of Katrina. I was working feverishly with many of my colleagues far removed from the area to be sure supplies and medical care would be available for those in need. It was a potential race against the clock; many people would be without vital medications, treatments such as dialysis and monitoring of their blood sugar and blood pressure levels. I was particularly concerned because I knew that the three states devasted by Katrina have the highest prevalence of diabetes -- almost 10 percent of the adult population has the disease. I also knew that historically they have had some of the poorest medical outcomes. Looking at the pictures of those left stranded, air-lifted to safety and arriving at shelters, I knew many would be in dire medical condition.

Diabetes is a potentially devastating disease that can adversely affect nearly every system of the body; it is diagnosed by an elevation of the sugar (glucose) level in the blood. When someone has diabetes, glucose cannot enter the body's cells because of either a deficiency of the key hormone insulin (type 1 diabetes) or because the body does not respond normally to insulin (type 2 diabetes). When sugar cannot enter the body's cells, the cells starve, the sugar spills into the urine (causing the cardinal symptoms of diabetes of excessive urination and thirst) and the person gets sick. Over 90% of people who have diabetes have type 2 diabetes and almost all of them are overweight or obese -- being overweight or obese in part causes diabetes. The term "diabesity" illustrates the critical connection between obesity and diabetes.

Currently, sixty-six percent -- or 2 out of 3 -- American adults are overweight or obese and they're all at elevated risk for diabetes. Over the last 3 decades, the number of obese and overweight children has tripled, 30% of nation's youth are now in this category and this has fueled an epidemic of type 2 diabetes in youth. When I was in medical school in the mid-1970s, type 2 diabetes was considered a disease of older adults. It has now become a disease of our children. As I sat glued to my TV watching pictures from Katrina, I knew many of those children and teens could have diabetes -- and some of them might not even know it. I also knew, as reported by the Centers for Disease Control and Prevention, that if they didn't have diabetes now, they have a one in three chance of developing diabetes sometime in their life.

An estimated 18.2 million Americans have diabetes, five million of these people have diabetes and don't know it. I wonder how many Katrina victims fall into that category? Even more ominous: more than twice as many people -- 41 million Americans -- have blood sugar levels in a higher-than-normal range, a condition we call pre-diabetes. They don't have diabetes yet, but they're on the path and have begun marching in the direction of this life-threatening disease. For years, my colleagues and I have been racing after them, trying to head them off. If we can pull them back from pre-diabetes, they may never develop type 2 or its dire complications of blindness, kidney failure, heart disease, stroke and amputation.

In my day-to-day life as a doctor, I see the human toll of diabetes. I know the rescue squads in LA, Mississippi and Alabama saw the devastation diabetes causes -- added to that of the hurricane itself. I know they saw children suffering with this unrelenting illness, pregnant women burdened, adults ravaged, and the elderly ready to be put in their graves. The economic costs of diabetes will add to the unfathomable costs of Katrina. Diabetes ranks number one for diseases in direct costs, consuming one healthcare dollar of every seven. In the U.S. in 2002, the tab for diabetes-related doctor visits, medications, hospitalizations, lost wages and lost work productivity was a staggering $137.7 billion. And unless the diabesity epidemic is reversed, these numbers will rise even more, particularly in Katrina's wake.

As we all spend time thinking about how we live our lives, if we are ready for a disaster in our own area, and what it means to be safe and well, we must examine if our modern day existence can be improved upon to diminish -- rather than augment -- our chances of getting diabetes. We must think of ways to have better food, healthy options, appropriate physical activity and adequate medical care to avert becoming obese and developing diabetes.

On one level, the solution is simple. Obesity, as we all know, results from consuming more calories than are burned in physical activity. In theory, all it should take to prevent the problem is for people to eat less and move more -- in other words, to become personally responsible for maintaining a healthy lifestyle. But obesity and diabetes are much more complex than that. The genes hidden inside each of our cells predetermine if diabetes can happen or not. In addition, a person's environment is critically important. The children and teens who develop type 2 diabetes typically live in families, go to schools, and inhabit neighborhoods where it's difficult to find nutritious, affordable food and safe places for physical activity. It appears this must be true for many of the people now affected by Katrina -- and as they rebuild or relocate it would be critical to ensure that going forward healthy options, nutritious food and physical activity are part of their new environments. We must be sure that the new economic structure does not make it cheaper for them to eat fries than fruit, and at the food industry and the mass media do not lure their children to consume what should not be consumed, and that they have access to preventive medical care.

We humans evolved over 2.5 million years and many thousands of generations. But our basic DNA has changed surprisingly little over the past 40,000 years. In other words, our genes were designed for living in caves, eating the plants we gathered and the animals we killed, communicating via smoke signals, and running around pretty much stark naked. Meanwhile, our lifestyle has altered dramatically. Only in the past few decades have our genes needed to figure out how to metabolize a bacon cheeseburger, soda, and fries. Our ancient genes and our modern environment have collided. As we help people rebuild their environments, and think about how to improve our own in anticipation that a disaster could affect us as well, we need to think about how we define progress. In the past, humans have defined progress in terms of the quantity rather than the quality of our food. We've also defined progress as the elimination of any requirement for physical activity in our jobs and for transportation, ignoring its importance for our health. And thanks to this brand of "progress," we've managed to devise a world designed to kill us -- particularly when faced with any added challenge such as an overwhelming natural disaster.

But we don't have to be the creators of our own demise. We don't have to watch 300 million people worldwide develop diabetes by 2020, as is presently projected. We have the opportunity to demand of our leaders, of our healthcare system, of our communities, and of our ourselves that the world become a place in which it is possible to live healthy -- in a world in which we can have normal blood sugar, normal blood pressure, normal weight, healthy meals, and a safe walk through the park. And the ability to withstand a disaster.