Fortnightly Club of Redlands

Our knowledge has evolved over thousands of years since man first learned to start fires. It has evolved in a slow methodical fashion. I have been fascinated how knowledge developed in many fields ultimately comes together synergistically to make the whole result greater then the parts.

I will examine a narrow segment of this evolution of knowledge and talk about how it has affected me as a consumer of today's healthcare approaches for insulin dependent diabetes.

A Consumers Point Of View

What ultimately became the major focus of my consumer needs came to me suddenly in 1971. I was 32. I began to experience extreme fatigue. My days at work seemed extremely long, and I had to run to the restroom almost continuously. My wife became concerned and tried to get me to see the doctor. As usual I told her that I would be fine. I reminded her that I just had a bad case of the Hong Kong Flu and had probably not completely recovered. After about two weeks I suddenly realized that I had lost about 15 pounds even though I was eating everything in sight. One Sunday I had a large dinner and decided I was still hungry. I then ate an entire box of Sugar Pops. My wife mentioned diabetes and again urged me to see the doctor. I said that that wasn't possible because no one in my family had ever been a diabetic.

Finally I felt so horrible that a doctor's appointment seemed like a wonderful idea. To the doctor my symptoms were very clear. To confirm his diagnosis he took a blood test and after several hours of waiting for the results I was admitted to the hospital with a diagnosis of diabetes mellitus.

I knew a little about diabetes because a family friend was diabetic. I remembered that he boiled and sharpened his insulin needles. I also remembered that he was supposed to be careful about what he ate. He wasn't. Obviously I had a few things to learn.

We talked to the doctor and the dietician. We learned that diabetes was different from most diseases in that you had to manage it. There was no cure. I would have to consciously manage my blood sugar to keep it within a normal range. It also meant that I would have to take daily injections forever and eat a planned diet. That wasn't very attractive but my choices were a little limited. I had a wife and three children and I was determined to live a normal life.

The doctor set my insulin level and the calories for my diet. The hospital dietician prescribed a diet that was known as an exchange diet. It was a high protein diet with limited carbohydrates. My diet and exercise would have to be predictable. I would eat 6 times a day on schedule to match the progression of the insulin.

I was also to check my urine with a litmus paper called Tes-tape. It indicated the level of glucose in my urine. If it turned various colors it would indicate a high blood sugar. I was to keep a record of these tests and bring it to my doctor's office. With this knowledge I left the hospital.

After I was released I followed the regimen prescribed by the doctor and dietician. I visited the doctor regularly to have a fasting blood glucose test and review my Tes-tape records. Based on the results minor adjustments to my insulin or diet were periodically made to maintain control.

Such was the state of diabetes management in 1971. How did we get there? Where are we today?

What is Diabetes?

The National Institute of Diabetes and Digestive and Kidney Diseases defines diabetes as a disorder of metabolism -- the way our bodies use digested food for growth and energy. The digestive juices break down most of the food we eat into a simple sugar called glucose. Glucose is the main source of fuel for the body.

After digestion, the glucose passes into our bloodstream where it is available for body cells to use for growth and energy. For the glucose to get into the cells, insulin must be present. Insulin is a hormone produced by the pancreas, a large gland behind the stomach.

When we eat, the pancreas automatically produces the right amount of insulin to move the glucose from our blood into our cells. Insulin is released when we eat. It is released in sufficient amounts to maintain blood sugar levels at the normal range.

In people with diabetes, the pancreas produces little or no insulin, or the body cells do not respond to the insulin that is produced. As a result, glucose builds up in the blood, overflows into the urine, and passes out of the body. Thus, the body loses its main source of fuel even though the blood contains large amounts of glucose.

The prevalence of diagnosed diabetes has been increasing dramatically over the past 40 years. Currently over 8 million persons have diagnosed diabetes. Approximately 5% require insulin injections to live. The other 95% use oral medication and life style changes for control.

The Early History

I didn't know it at the time; but I was very lucky. Only 50 years before had enough knowledge been developed to allow me to live. Before 1922 I would have died within a very short time. To appreciate these changes we need to look back in history.

Imagine, as we look at how knowledge has evolved that you are a hard working young man. Suddenly you are urinating far more frequently than you ever have before. You are constantly hungry and eat everything you can. You friends tell you that you are getting thin. You are constantly tired.

In prehistoric times your illness would most likely have been considered the work of malevolent demons. Some medical knowledge did exist. Usually medical therapy mounted directly against a disability was the most successful. Medical procedures practiced in ancient societies included cleaning and treating wounds by cautery, poultices, and sutures. Physicians reset dislocations and fractures, and used splints. Additional therapy included the use of purges, diuretics, laxatives, emetics, and enemas. Perhaps the greatest success was achieved by the use of plant extracts. So successful were these that 50 or more continue to be used today. Digitalis a heart stimulant extracted from foxglove, is perhaps the best known.

Since your illness was not a visible wound or minor ailment your primary treatment would probably have consisted of incantations, dancing, magic effects, charms and talismans, and various other measures. You would have died in short order.

Approximately 3500 years ago in Egypt physicians emerged as an early form of scientist, distinct from the sorcerer and priest. The physician normally spent years of arduous training at temple schools in the arts of interrogation, inspection, and palpation.

In these days the physician would ask you questions examine your overall condition and perhaps offer you some roots or other medications. Most but not all patients died in relatively short periods of time.

The earliest written evidence of diabetes was an early Egyptian medical text written around 1550 BC, called the Ebers Papyrus. It describes a condition of "passing too much urine." The Greek physician Aretaeus, who lived in the second century A.D., gave diabetes its name, from a Greek word meaning "siphon" or "pass through." Aretaeus observed that his patients' bodies appeared to "melt down" into urine. It was again noted in the writings of the Hindu physician Sussruta in the 4th century AD.

By the 3rd century BC, Egypt, the seat of a famous medical school and library, was firmly established as the center of Greek medical science. In Alexandria the anatomist Herophilus performed the first recorded public dissection. Important work on the anatomy of the brain, nerves, veins, and arteries was carried out.

In the 7th century the Arabists elevated professional standards by insisting on examinations for physicians before licensure. They excelled in the fields of ophthalmology and public hygiene, introduced numerous therapeutic chemical substances, and were superior to the physicians of medieval Europe.

Early medieval Europe suffered from complete disorganization of the lay medical fraternity. To provide medical care, a form of ecclesiastical medicine arose; originating in the monastic infirmary, it spread rapidly to separate charitable institutions designed to care for the many sufferers of leprosy and other disorders. The Benedictines were especially active in this work, collecting and studying ancient medical texts in their library at Monte Cassino Italy. St. Benedict of Nursia, the founder of the order, obligated its members to study the sciences, especially medicine. The abbot of Monte Cassino was himself a famous physician.

By the end of the 12th century the revival of lay medicine and restrictions on activities outside the cloister brought about the decline of monastic medicine, but it had performed a valuable function by preserving the traditions of medical learning. In the 13th century, dissection of the human body was permitted, medical licensure by examination was endorsed, and strict measures were instituted for the control of public hygiene, but scholastic medicine remained largely a logical exposition of ancient dogma.

The English philosopher Roger Bacon was the first scholar to suggest that medicine should rely on remedies provided by chemistry.

In the 17th century Thomas Willis having investigated the anatomy of the brain and the nervous system, was the first to distinguish Diabetes Mellitus. After the discoveries of Copernicus, Galileo, and Newton, 18th-century medicine began to adapt to the formal scientific disciplines we know today.

Early observers noted that urine from people with diabetes was very sweet. In fact, one test to diagnose diabetes was to pour urine near an anthill. If the ants were attracted to the urine, it meant that the urine contained sugar. By the eighteenth century, physicians added the Latin term mellitus, which describes the sugary taste of diabetes.

It wasn't until 1776 that scientists discovered that glucose was in the blood of both people with diabetes and people who didn't have diabetes. That led them to suspect that people with diabetes pass sugar from the blood to the urine. But they didn't know why or how.

In 1889, more than 100 years after glucose was found in blood, two German physiologists, Oskar Minkowski and Joseph Von Meting found by accident that the pancreas was involved in diabetes. They were investigating how fat is metabolized in the body. They decided to remove the pancreas from a laboratory dog. Much to their astonishment, the dog urinated again and again. Fortunately, they had previously tested the dog's urine for glucose because the dog developed diabetes when its pancreas was removed.

This led the scientists to suspect that some substance in the pancreas somehow prevented diabetes. Scientists embarked on a 30 year quest to find that magic substance. Physicians treated their patients with a host of so called cures, including bloodletting, opium, and special diets. Unfortunately, none of these measures helped the disease. Although some diets seemed to help some older people with diabetes, they did nothing for severely affected young patients.

Scientists and physicians had developed much basic knowledge. However over a period of 3300 years little had changed for the patient.

TWENTIETH CENTURY PROGRESS

In 1921, Dr. Frederick Banting, a young surgeon just out of medical school, had a breakthrough. He isolated the groups of cells called the Islets of Langerhans in the pancreas. Working in the laboratory of a senior faculty member at the University of Toronto, Professor J.J.R. Macleod, an authority on carbohydrate metabolism, Banting began his experiments. Macleod teamed Banting with a young medical student named Charles Best.

The biggest breakthrough came in 1922 when Frederick Banting and Charles Best conducted a series of experiments.

Using laboratory dogs Banting tied off the pancreatic duct, which connects the pancreas to the intestine. This would destroy most of the tissue of the pancreas, which would no longer be able to secrete its digestive enzymes into the intestine. Banting guessed that the islets of Langerhans secrete something directly into the blood and that these cells would survive. At long last, they succeeded in treating a dog with diabetes using extract from the islet cells. They painstakingly took fluid from healthy dogs' Islets of Langerhans, injected it into the diabetic dogs and restored them to normalcy for as long as they had the extract.

Within 6 months after their success the two scientists injected their extract into Leonard Thompson, a 14-year-old boy who was dying from diabetes, but the boy remained ill. A biochemist working in Macleod's laboratory, J.B. Collip, purified the extract, and the experiment was re-peated 12 days later. This time the scientists succeeded, and the boy, emaciated from diabetes, began to gain weight. He lived for 15 years with regular insulin injections, until he died from pneumonia in 1928.

Banting and Macleod were awarded the Nobel Prize in Medicine for their discovery. Feeling that their collaborators had been slighted, Banting shared his prize money with Best, and Macleod shared with Collip. The team had made an important discovery leading to a diabetes treatment that is still in use today.

The University of Toronto immediately gave pharmaceutical companies' license to produce insulin free of royalties. In early 1923, about one year after the first test injection, insulin became widely available, and began to save countless lives.
Now for the first time in history the physician could actually give patients the hope of living. The patient had to take insulin injections daily and was told to live a very predictable life. Each day the patient would take the same insulin injections, the same amount of food and the same amount of exercise. But you could live. There were side effects. You could get hot and shaky or you could get queasy and tired. These are signs of glucose levels that are either too high or too low. Once you made the appropriate corrections you would feel fine.

Diabetes still could not be cured but it could be managed. The patient had to be intimately involved in managing his own metabolism. Scientists learned that initial insulin levels could be based on body weight and subsequent adjustments made from the blood glucose tests. Predictability was essential.

Insulin therapy while generally successful was difficult. The patient had to manage their life in a strict predictable manner to avoid poorly understood variations. Very few people are capable of such absolute predictability. Much work remained.
The relationship between insulin, food and exercise had to be refined in sufficient clarity to allow patients to manage their own health.

For safety, the patient had to be very aware of their feelings to determine if their glucose was high or low. If your blood glucose is too high you will pass into a coma. If your blood glucose is too low you will lose consciousness. Such awareness is less than reliable and does deteriorate over time. This is particularly true with hypoglycemia or low blood sugar. Diabetics did their best to follow a fixed plan in a highly variable world. Almost anything (slow restaurants, a cold, too much exercise, unanticipated overtime, a hidden infection, or a holiday celebration) could cause deviation from the tight control level the physician devised.

The only way to determine blood glucose was with a lab test conducted in the doctor's office. Results were not available in time to take any appropriate action. The tests confirmed that the patient was in or out of control at the time of the test.

New issues evolved. Poorly controlled diabetics suffer complications of diabetes. These include blindness, cardiovascular disease, kidney disease, ketoacidosos and neuropathy.

Obviously more progress was still needed. Since 1922 changes have rapidly evolved. The changes are still dramatic in their effect.

Balance and Control

Since the discovery of insulin, diabetics have been told that there are three primary parts to the balancing their life to live with diabetes. They are insulin, diet, and exercise. For the diabetic to live long and healthy in a perfect world:

You inject exactly the amount of insulin you need to use the glucose generated by the food you plan to eat. This occurs several times a day. The number of times varies depending on the regimen your healthcare team has worked out with you.

You eat exactly what you need to provide energy for your activities, maintain a healthy weight, and provide the vitamins and minerals to keep healthy.

You exercise just enough to use exactly the energy provided by the glucose converted by the insulin.

Insulin

Lets start with the insulin. Insulin enables the body to process food into energy. Natural insulin acts rapidly. A properly functioning pancreas releases insulin on a continuing level just to maintain body functions. When we eat it releases the exact amount necessary to convert glucose to our cells for future use.

Initially manufactured insulin was derived from either beef or pork. It had many impurities and an inconsistent strength. Early insulin dependent patients could follow the prescribed regimen exactly and still experience difficulty because the insulin had significant variability.

Technology has refined insulin to a reproducible product that is similar to human insulin. Manufactured insulin is usually injected several times a day. The release rate is fixed into the insulin. Typically injected insulin lasts in the body for 24 to 36 hours. A risk of hypoglycemia or low blood sugar occurs 6 to 12 hours after injection. To accommodate variable life styles pharmaceutical companies developed short acting, intermediate acting, and long acting insulin. . A 6:00 AM injection means that you must eat lunch and dinner on time before lows are likely to occur.

Manufactured insulin is relatively slow. Natural insulin acts immediately and is secreted continuously. Ideally injected insulin would mimic the body's secretion and response. Scientists have attempted to provide this imitation by combining insulins of different reaction times.

In 1978 insulin became the first human protein to be manufactured through biotechnology. The result was human insulin, without the problems animal insulin sometimes causes. Today, almost all diabetics use recombinant human insulin instead of animal insulin.

Until recently, manufactured insulin has fallen into three categories that describe their duration in the body. In 1996 the Food and Drug Administration approved a modified human insulin called Lispro (brand name Humalog) which was specially developed to be active very quickly after injection.

Types of Insulin Available

Insulin type	Onset	Peak	End	Lows most likely at
Natural	Immediate	0.5 to 1 h	N/A	N/A
Lispro	0.25 h	.1 to 1 1/2 h	4 h	1 1/2 to 4 h
Regular	0.5 to 1 h	2 to 3 h	8 h	3 to 7 h
NPH Lente	2 to 4 h 3 to 4 h	4 to 10 h 6 to 12 h	22 h 24 h	6 to 13 h 7 to 14 h
Ultra-Lente	6 to 10 h	10 to 18 h	36 h	10 to 22 h

The slow release Lente or Ultra-Lente mimics the constant secretion of insulin to allow a continuous conversion of glucose to support the body's normal basic functions. This is the basal rate for insulin. The fast acting lispro injected just before a meal mimics the release of insulin by the pancreas when food is taken.

Eli Little and Company, 1996, 1999

These evolving approaches using injected insulin have effectively allowed diabetics to live significantly longer lives. However, exact replication of the body's actions is still not perfect and many diabetics experience complications that result from inadequate control of their glucose level.

Diet

To live a reasonably normal life the diabetic has to balance dietary intake with insulin and exercise.

Medical science has learned that carbohydrates primarily provide the glucose available for conversion. Initially, after the discovery of insulin, dietary carbohydrates were kept at a minimum because they caused the largest impact on glucose levels. Today dieticians advise patients to eat a healthy diet that includes a balance of all healthy foods. The diabetic needs to estimate and manage their carbohydrate intake. But, who can realistically calculate the carbohydrates they eat? Food lists are available in paperback books that give food content. However, it still takes a good eyeball and much experience to know what you can reasonably eat. Care to guess how many carbohydrates are in that Burrito Grande at Cuca's?

To put this in perspective one piece of bread can raise my blood sugar 50 points if I don't anticipate that bread with the right dose of insulin. If I catch a cold the effect might be an increase of 100 points. The normal range of glucose is from 70 to 110 or only 40 points. Therefore if I overeat my 6:00 AM plan by one silly little slice of bread my glucose would be 50 points above normal. Obviously I need to be very precise about insulin doses and food portions.

During the first several years after I was diagnosed I not only regained the weight I lost during my initial illness but ballooned out to a portly 40 pounds overweight. Control became difficult at best. I was on a rollercoaster of highs and lows. At this time I found a doctor that specialized in diabetes and learned more than I had read in books. My wife and I spent several months working with a dietician. We learned the principles of diet and changed our eating habits significantly. I lost 55 pounds and regained control.

Exercise

Exercise is the third traditional element of the balancing plan. Of course exercise is good for everyone. It makes you feel good, it improves your physical fitness and generally improves your self-confidence. For the diabetic, exercise lowers blood glucose and improves insulin sensitivity.

In addition to helping manage current glucose levels exercise is a great moderator. It sharpens the mind, tones the body, improves heart strength, reduces stress and fatigue, reduces body fat and improves cholesterol readings. One hour of exercise on a bicycle has reduced my blood sugar by over 100 points. The benefits of exercise last for 24 hours. Therefore, daily exercise is a must. Anticipation of that exercise in my diet and insulin levels is also a must.

For me exercise was essential if I were to be with my children as they grew up. After I learned to manage my insulin and diet I began to ride a bicycle regularly and developed enough stamina and strength to deal with my children's outings in Boy Scouts and Girl Scouts. Remember in the early days after insulin was discovered exercise was often discouraged. I eventually learned how to manage everything and progressed to 90 mile bicycle rides and weeklong backpacking trips in the Sierras with my sons' Boy Scout Troop. Other even competed in the Hawaii Ironman competition. Given the lack of clear monitoring methods exercise seemed to enable me to maintain adequate control.

Self Management

I have often think of diabetes management as driving a car. The gas pedal makes the car go and the brake pedal stops it. The speedometer tells how fast you are going. However if you don't watch the speedometer you can get used to speed and soon you are exceeding the speed limit. How does the diabetic know when he is speeding?

Until the early 1980's the diabetic's speedometer had been awareness of how they feel. Fatigue and thirstiness indicating high blood sugar or hungry and shaky indicating low blood sugar. Based on these feelings appropriate action had to be taken.

In the mid-1980's the needed speedometer became widely available. It was a compact test device that allows an individual to test their blood glucose and get an answer within one minute. It was a product of evolving blood test techniques, computer technology and miniaturization techniques.

Test results are obtained from a finger prick of blood. Today's meters not only test the glucose level but also have added memory and computing capacity to aid the diabetic in analyzing trends.

Glucose meters allowed the patient to tailor insulin injections to current glucose levels, the actual time of meals and the content of meals. The techniques that evolved to integrate diet, exercise, insulin and test results are called flexible intensive management. Mixed insulin injections which combined the benefits of faster acting regular insulin with slower acting insulin became more common.

Self testing is now the fourth part of the balancing program to control diabetes.

The Team

Medical treatment became a team effort intended to guide the patient to control their diabetes. The team included the patient, the doctor, a certified diabetes educator (usually a registered nurse or dietician) and a registered dietician. Together they worked out the techniques that work best for each individual.

What is your number?

Armed with this information, one can knowledgeably adjust insulin, medication, diet, and exercise regimens to stay in tight control. But what is tight control?

Interestingly enough at this relatively advanced stage no one had yet clearly demonstrated in a scientific manner that the underlying assumption of diabetes management was valid. Again this assumption was that keeping blood glucose close a normal range would truly extend the diabetics life and maintain good health. With flexible intensive management and self glucose testing a trial could be designed and conducted. However how could degree of control be compared?

In the late 1970's a new lab test was developed. This test, the HbA1c or Glycosylated Hemoglobin test, enabled physicians to determine the time average glucose level in the patient over the prior two or three months.

The HbA1c blood test measures glycosylated hemoglobin, a molecule in the blood that allows them to gauge how well they have controlled their blood glucose during the previous two to three months. Daily blood glucose testing provides only a snapshot of glycemic control at the moment you test. The HbA1c test gives you the big picture by showing how you have managed your glucose levels during the previous two to three months.

The HbA1c measures the concentration of glycosylated hemoglobin molecules in the blood. Glycosylated hemoglobin forms when hemoglobin molecules link up with glucose molecules. The more glucose in the blood, the more hemoglobin becomes glycosylated. Once glycosylated, hemoglobin stays that way until the red blood cell dies after about 120 days. The HbA1c test can thus determine your average blood glucose level for the previous two to three months. The result is given as a percentage. Nondiabetics typically have HbA1c readings of about 4 to 5.5 percent.

Does it all help?

The first comprehensive study to prove the underlying assumption of diabetes management was sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases. It proved that keeping blood sugar level as close to normal as safely possible reduces the risk of developing major complications of diabetes. Many studies have shown that keeping HbA1c level at 8.1 percent or less helps prevent diabetes related complications.

The 10 year study, called the Diabetes Control and Complications Trial, was completed in 1993. It included 1,441 people with insulin dependant diabetes. The study compared the effect of two treatment approaches. These were intensive management and standard management on the development and progression of eye, kidney, and nerve complications of diabetes. Researchers found that study participants who maintained lower levels of blood glucose through intensive management had significantly lower rates of these complications.

Close control of blood glucose levels reduced the risk of eye problems up to 76%: nerve damage 60% and severe kidney problems 56%.

The Pump

This study also demonstrated the value of another new high tech device called an insulin pump. An insulin pump is a battery powered computer controlled electromechanical device about the size of a pack of cigarettes. It contains a reservoir of insulin connected to tubing and a cannula or needle, which is inserted subcutaneously. The patient programs the computer to deliver a basal rate of insulin. The patient can give additional insulin releases called boluses in conjunction with meals or if testing indicates that blood glucose levels are excessive.

Four years ago I was placed on an insulin pump to improve control of my glucose levels. I discovered an entirely new level of sophistication in the tools available to help me. Insulin is delivered continuously. It is delivered as a basal rate with boluses that I program for meals. In conjunction with the pump is an intensive testing program requiring a minimum of six blood tests per day. These tests are taken before each meal and between meals to assure glucose is close to normal.

When my doctor originally suggested an insulin pump I was skeptical. I did not like the idea of continuous attachment to a box. I read many flowery endorsements that told how others benefited. I met with the manufacturer's representative but there was no one to talk to with direct experience. I was the first Inland Empire guinea pig.

It did not take long for me to change my mind. For the first time in 24 years I was no longer under the tyranny of the slow acting insulin shot taken at 6:00 AM controlling that controlled when I had to eat lunch and dinner. It also allows flexibility in what can be eaten. If I wanted to eat more I could. Using a pump in conjunction with fast acting insulin I could quickly bring down high glucose levels. The short acting insulin combined with regular self-testing also minimizes the possibility of low blood sugars.

With a pump and a glucose meter you now have a method to know when to step on the gas or when to step on the brake. You can realistically have a banana split and still keep your blood glucose close to normal. Or you can safely miss a meal knowing that you will not experience low blood glucose leading to shakiness or unconsciousness.

In addition with the pump and the tests I have been able to keep my long term glucose levels below the level at which long term damage occurs.

Almost everyone who uses a pump gains greater blood glucose control. Over time, improved control significantly reduces your risk of chronic Diabetes complications. Insulin pumps also help you live a more normal life: You can eat and exercise when you want and how you want with less fear of experiencing blood glucose ups and downs.

An insulin pump is not an artificial pancreas. It can't measure your blood glucose level or automatically adjust the amount of insulin you receive. To use a pump, you must be willing to test your blood glucose at least four to six times a day and learn how to adjust insulin, diet, and exercise in response to those test results.

More Advances

In recent years, other advances in diabetes research have led to better ways to manage diabetes and treat its complications.

What Will the Future Bring?

In the future, it may be possible to administer insulin through nasal sprays or in the form of a pill or patch. Devices that can "read" blood glucose levels without having to prick a finger to get a blood sample are also being developed.

Scientists are looking for genes that may be involved in diabetes. Some genetic markers have been identified, and it is now possible to screen relatives of people with diabetes to see if they are at risk.

The new Diabetes Prevention Trial Type I identifies relatives at risk for developing insulin dependent diabetes and treats them with low doses of insulin or with oral insulin like agents in the hope of preventing future occurrences.

Transplantation of the pancreas or insulin producing beta cells offers the best hope of cure for people with insulin dependent diabetes. Some pancreas transplants have been successful. However, people who have transplants must take powerful drugs to prevent rejection of the transplanted organ. These drugs are costly and may eventually cause serious health problems.

Scientists are working to develop less harmful drugs and better methods of transplanting pancreatic tissue to prevent rejection by the body. Using techniques of bioengineering, researchers are also trying to create artificial islet cells that secrete insulin in response to increased sugar levels in the blood.

For non-insulin dependent diabetes, the focus is on ways to prevent diabetes. Preventive approaches include identifying people at high risk for the disorder and encouraging them to lose weight, exercise more, and follow a healthy diet.

Bibliography

The National Institute of Diabetes and Digestive and Kidney Diseases of The National Institutes of Health. Diabetes Overview. Publication No. 96-3873. October 1995. Last updated: 6 August 1996

SUMMARY

Background of the Author

Introduction

A Consumers Point Of View