If more doctors followed guidelines for adult diabetes testing, and if more patients requested the tests, fewer would suffer the sometimes deadly consequences of this epidemic disease.
As a legal secretary at a major law firm, it seemed natural to Beverly Cook that increasingly she was very tired much of the time. After all, she worked long hours, and she was overweight.
So when she got her finger pricked for a screening test at an office-building health fair, she could hardly believe the results showed she had type 2 diabetes.
“I was never even suspicious,” said Cook, who didn’t know that fatigue is a symptom of diabetes.
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Nor had she been tested for the disease during annual physicals for at least two years despite her major risk factor of being at least 50 pounds overweight.
Cook, 60, was among millions of people nationwide who are at risk for the potentially fatal disease and aren’t being tested when they should be. Physicians and patients alike need to do a better job of being wary of the disease that is reaching epidemic levels worldwide, experts say.
“If you treat diabetes as early as possible to keep glucose as normal as possible, you can potentially prevent complications,” says Dr. Steven Kahn, who led the Seattle portion of the national Diabetes Prevention Project, completed in 2001, and is director of research at the Veterans Administration Puget Sound Health Care System.
About 17 million people in the United States have diabetes, and about one-third don’t know it, according to the American Diabetes Association. Another 20 million Americans are at risk for the disease, and more than 70,000 a year die of complications from the disease. About 95 percent of diabetics have type 2 diabetes, which is most common in adults older than 40 but increasingly is affecting younger adults and even teenagers.
Diabetes is the leading cause of kidney failure, limb amputations and adult blindness, and is a major cause of heart disease, stroke and high blood pressure. Costs for treatment and lost productivity last year were nearly $132 billion.
The prevalence of the disease has increased steadily over the past 10 years. About one in three people born in 2000 will develop diabetes in their lifetime, the Centers for Disease Control and Prevention (CDC) estimated in a report released today. Generally, researchers believe that’s because of the rising number of Americans who are overweight and better reporting of newly diagnosed patients.
A recent University of Texas study concluded that if screening guidelines adopted by several professional medical societies were followed, virtually all diabetes cases would be found. The societies are comprised of physicians who treat diabetics.
Formulated by a committee of experts appointed by the American Diabetes Association with representatives of the World Health Organization, the guidelines recommend diabetes blood tests every three years beginning at age 45 for all adults. But the committee said tests should be given earlier and more often to those with a risk factor for the disease, such as being overweight, being a racial minority, having a family history of diabetes or having high blood pressure.
The Texas scientists analyzed data from the National Health and Nutritional Examination Survey, which is done periodically and is representative of the U.S. population. They concluded that if doctors tested everyone with a single risk factor, they would catch close to 100 percent of all the new cases. Testing those with two or more risk factors would catch 98 percent of new cases, they said.
“Efficacious guidelines exist, but implementation of the guidelines remains the greatest challenge,” researchers Florence Dallo and Susan Weller said in an August report of the “Proceedings of the National Academy of Sciences.”
Kahn and other physicians say doctors but also patients are at fault for the lack of timely diabetes screening in many cases.
Physicians sometimes don’t remember to do the tests because they are swamped with other recommended screenings, said Dr. Jean Marshall, president of the Washington chapter of the American Academy of Family Physicians. These include, especially for older adults, checks for high blood pressure; high cholesterol; osteoporosis; colorectal, skin and cervical cancer; and current immunizations.
“We need new (computer) systems that help remind us of the diabetes screening,” said Marshall, a Bellevue physician.
Marshall believes doctors also may have less incentive to do the screen because insurance payments are low. The extra payment for a blood draw during an office visit is about $3, and for the lab test, about $10. In addition, Medicare doesn’t pay for a screen unless the patient is having diabetes symptoms.
“We should be the safety net. We shouldn’t miss (recommended tests),” said Marshall.
Kahn and Marshall also say many patients don’t get tested because they don’t get regular checkups, don’t have health insurance, or don’t get the tests ordered by their doctors. In addition, some patients go only to specialists, most of whom don’t consider diabetes screening their responsibility.
Dr. Maureen Callaghan, immediate past president of the Washington State Medical Association and an Olympia neurologist, simply dismissed the Texas study’s finding that doctors would find almost all diabetes cases if the professional screening guidelines were followed: The researchers “make assumptions that can’t be substantiated,” she said.
Callaghan said “it’s a possibility” that some doctors don’t test for diabetes when they should. But she said it’s more likely most patients don’t go to the doctor when they should.
Kahn and Marshall said ensuring timely screenings are both the physician’s and the patient’s responsibility: “Education about this can come from both sides, and the patient shouldn’t be loath to educate the physician,” said Kahn.
A heavy toll
When diabetes takes hold without treatment, it soon takes its toll. Beverly Cook, the retired legal secretary, knows all too well.
She saw her physician immediately after the health-fair blood test three years ago showed she probably had diabetes. Further tests confirmed the disease, and her doctor told her to watch her diet, lose weight and exercise. By cutting out sugary foods, she brought down her blood sugar significantly, but not within a safe range, and she didn’t lose much weight. She also didn’t exercise.
After retiring a year ago, Cook got serious about her disease and volunteered for the Look AHEAD study, a federally sponsored program to examine long-term effects of weight loss in preventing heart attacks, strokes and other complications of type 2 diabetes. But during treadmill testing for the program, she learned she was at serious risk for a heart attack.
She had slight chest pains on the treadmill and soon after while walking around at Virginia Mason Medical Center. That night, the pains increased and she returned to the hospital’s emergency room, where she was scheduled for an angioplasty within hours.
“If it had gone into a full-scale heart attack, I might not have survived,” said Cook, sitting next to her husband, Bill, who has had two heart attacks. “I feel a real commitment to the Look AHEAD study.”
Now Cook, a Lake City-area resident, meticulously records all her meals in a diary. Two meals a day consist of a diet shake, and she limits her total calories to 1,500 a day. She walks 35 minutes a day five days a week, tests her blood sugar twice a day, takes a diabetes medication and attends a weekly class on diabetes control.
“In the past, I haven’t paid a lot of attention to myself. … But this is all something I have to work into my schedule. I have to be willing to look out for myself,” says Cook.
Cook almost became an example of what University of Texas researchers found in another study: Diabetics have the same chance of a heart attack as people who already have had one heart attack.
Excess weight increases risk
Researchers have often reported the increased risk of diabetes from being overweight. Those who are obese have more than seven times the risk of the disease as those of normal weight, according to a recent CDC study. And in 2001, nearly 21 percent of Americans were obese, the study found in an extensive survey. Obese is defined as having a body mass index (BMI) of 30 or above; the index is based on height and weight.
David Haan, 63, has struggled with obesity since he was a boy. Much of the time he has been losing the battle. He has had diabetes for 11 years and last year had to have half his right foot amputated because a quickly spreading infection from a callus that wouldn’t heal was threatening his life.
When he grocery shops near his home in Edmonds, children often stare at his special open-toed shoes. He wiggles his remaining toes and points to each of his feet: “These little piggies went to market,” says the retired engineer, ” and these little piggies went to heaven.”
Not only is Haan’s sense of humor intact, but so, at last, is his resolve mostly. One-dollar specials on cheeseburgers (“an invention of the devil”) can still cause a slip. So can sales of his favorite candy bars. “I should be barred from all supermarkets,” he declares.
But he’s in the Look AHEAD program now. He works out one to three times a week at a gym, keeps a diary of his food intake, takes insulin injections and goes to the program’s regular educational meetings. He knows he must do this to prevent any more of the often devastating complications of diabetes.
“You have to make a lifelong change in your eating habits,” he says, sipping on a diet shake and reinforcing to himself the truth that he knows.
“You have to lose the weight, you have to be engrossed in that. You have to really be a fanatic about getting your weight under control.”
Warren King: 206-464-2247 or firstname.lastname@example.org