Wednesday, May 26, 2010

Attitudes about curing diabetes

A recent visit to the eye doctor bumped me up against the contradiction at the heart of the medical community's attitude towards diabetes.

It has been an uphill battle for doctors to get people to understand that diabetes is a chronic, lifelong condition. Most people have a vague notion that you just have to avoid sugar and take your medicine every few hours, and you're fine. Diabetes usually appears in movies as an excuse for a character to need their medicine now Now NOW NOW or they'll die! (when for the vast majority of diabetes sufferers, the only immediately life-threatening need they'll face is a need for food if they took their insulin a little while ago and then missed the planned meal).

At least, that's how it was ten years ago. Nowadays, while Hollywood still insists on using diabetes as a ticking time bomb plot device, huge increases in the rate of diagnosis mean most people know someone who is diabetic and probably have picked up a little bit more about it, and lots of public education has also made a dent. People have gotten the message that diabetes requires a lifetime of care. There's more awareness of being "prediabetic" (which is often a euphemism, sometimes for "you're diabetic, but we think you'll be better motivated to take care of it if we call it this instead", and sometimes for "you need to eat better and exercise more, and this is a way to strike some fear into you"). And this public education also includes educating the medical community; while gastroenterologists might be up on these things, your GP might lag a while, and your dentist probably learns about it the same way you do.

So just about when they're getting us to take diabetes seriously and understand it, a complication arises. It turns out that there has been evidence for a few decades now that gastric bypasses can resolve -- that is, "cure" -- diabetes. This has been known for a long time but not publicized even within the medical community for the simple reason that no one really understands precisely how it works. It's also very easy to misunderstand. "Fat people get diabetes. Gastric bypass makes you lose a lot of weight. Ergo, the loss of weight is how it works." Well, no. It turns out that in the majority of cases, diabetes measures like blood sugar drop precipitously in the first few weeks after the surgery, long before there's been enough weight loss to matter (losing that same amount of weight by other means would not be expected to, and does not, lead to significant changes in blood sugar levels). Something fundamental and metabolic changes, probably something to do with the extensive nervous system around the stomach (almost as complex in scale as the brain, yet barely understood), that leads to an almost immediate resolution.

We get stuck in a bit of semantics at this point. After gastric bypass, am I "cured", or is my diabetes merely in "long-term remission"? Yes, it's possible in ten years I could become diabetic again, particularly if I find ways to regain a lot of the weight. But if I had never been previously diagnosed and someone checked me out now, my fantastically normal blood sugar levels would soundly put me into the class of "not diabetic, not even at high risk to be diabetic". I don't really have a higher risk of becoming diabetic than someone else of my current weight who hadn't been through being diabetic and having a gastric bypass -- in fact, probably less, since regaining the weight, though possible, is less likely.

The insurance companies still treat diabetes as a life-long condition, and we don't argue the point too strenuously because that makes them more likely to authorize some things that the doctors ask for, that are probably no longer needed. That's where my eye doctor's office comes in. They still want us to come in for an annual checkup, because that's standard procedure for diabetics, even though our blood sugar levels are probably better than 90% of their never-been-diabetic patients. They don't quite come out and say "no you aren't" when we refer to ourselves as "cured" but it's clear that that's how they think of it. They haven't gotten the news, or aren't convinced of it; and they treat us like we're oversimplifying or being in denial. They're very polite about it, in fact, exceedingly friendly, cheerful, and upbeat, praising us for our sugar levels, our weight loss, our exercise regimens, and the condition of our eyes (particularly mine, which remain perfect at the age of 42), but it's still there.

I guess they had to fight a long time to get people to take diabetes adequately seriously, and understanding it as a permanent condition that is, at most, "in control," was a big part of that, so they're loathe to let it go. No one wants to be the first to say "cured" officially (except the people who do the gastric bypasses, and even they are cagey about it), because of the fallout (both legal and in terms of public perception) if they end up wrong.

Yet the evidence keeps mounting. Even the ADA, which is notoriously conservative (still recommending the high-carb diet that has been proven time and again to be bad for diabetics), has come close to calling it a 'cure' by now. In the end, my blood sugar is probably lower than that of the majority of people around me, including skinny, athletic, unabashedly "healthy" people; and my risk of diabetic complications is as low as theirs, or lower. What's the real point of calling me "a diabetic in remission"? To "trick" me into exercising? Maybe for some people that works, though it's a sad commentary if it does.

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