The Sugar State
Obesity tends to overshadow Michigan’s true No. 1 killer — diabetes. The main problem? How we live our lives every day
Greg Williams (left) received treatment for his diabetes from Dr. Mark Beard (right).
When he was diagnosed with diabetes, Greg Williams was shocked. As a naturally gifted athlete, Williams never bought what his sister was selling when she would ominously say, “You either become a schizophrenic or a diabetic.”
To be fair, his sister was schizophrenic. And he’d lost a cousin at 29 to diabetes. But this family history, he thought, wasn’t going to happen to him.
If Williams wasn’t eating or sleeping, he was outdoors and active. He ran in the 10K portion of the historic Crim Festival of Races that wound around his hometown of Flint. Being in by nature was his thing. He lived and breathed basketball at a fast-paced, competitive level. It was a sport Williams saw himself playing well into his 60s.
But in 1991, at the age of 32, that became harder to picture. There was no denying the diagnosis of Type 2 diabetes — or the symptoms that were starting to settle in.
“When you start getting the symptoms, you’re scared,” says Williams. “I was getting the blurred vision, the thirstiness, the hunger. Being an athlete, I stayed ahead of the game. When I slowed down, it caught up with me. The doctors said I probably had this disease a long time and didn’t know it. They tell you to get on your medication and what to eat … but when you’re young, it’s hard to discipline yourself. I was scared, but I didn’t believe I needed insulin.”
Williams just wasn’t ready to give up his lifestyle — one that contributed to his disease with a poor diet and no treatment while simultaneously keeping it under control with exercise.
Years passed. Williams sought no additional treatment, even as the disease wreaked havoc on his nervous system. The pain wouldn’t let him sleep. Blindness set in, making him paranoid. He clung to his independence by continuing to drive — running red lights and stop signs. He saw cars that weren’t there. His wife and children were becoming silhouettes. He couldn’t remember what their faces looked like.
Extended hospital stays became a constant. In 1996, Williams underwent double cataract surgery. Soon after, his foot developed a gaping diabetic ulcer, officially benching him from his active life. By 2006, the ulcers paved way for bilateral amputation — his left leg on his own terms; his right the following year after discovering a maggot infestation in his foot.
“It was the beginning of the end,” says Williams. “You’re telling someone who used to be active that now I have to stay off my feet? If I stayed active, I did good, but I couldn’t anymore. The disease was ravaging my body.”
When Dr. Mark Beard met Williams in 2011, Williams was living in a dumpy, second-floor apartment in Flint. Steep stairs. No handicap ramp. Fresh from a four-month hospital stay and with only ill-fitting prosthetics to get around, he was trapped inside. A fist-sized pressure ulcer formed over his sacrum and communicated with his bowel, unleashing a rotten stench.
After administering lab tests, Beard — a physician with the Visiting Physicians Association — discovered Williams’ hemoglobin A1C (an average of blood-sugar level over three months) was at 12 percent. To put that in perspective, someone without diabetes hovers under 5.7 percent; someone with untreated Type-2 diabetes for an extended period is around 8 percent.
It was the worst case of diabetes that Beard had ever seen.
For the next five months, Beard worked with Williams, then 52, to alleviate his aversions to treatment. He secured properly fitting stockings for Williams’ prosthetics, allowing him to leave his apartment. He eased him into a regimen, administering one or two units of Lantus (a long-acting insulin) at a time. He educated Williams on his disease in a way no doctor had taken time to do — even after years of being in and out of hospitals.
A complete 0-to-60, under-the-hood overhaul of how we live and how we eat can be overwhelming. With a little extra help from Beard, it started to work for Williams.
“He’s an intelligent man with such insight into his situation, but he’s also learned some hard lessons,” Beard says. “There was a lot of convincing him to go on treatment. He thought it would hurt him. Whether or not that’s because of poor care or his own stigma, who knows? It’s hard to point a finger at anyone in particular.”
A ‘WALKING CANDY BAR’
As with so many chronic illnesses in this country, we often don’t pay attention until they affect us in a profound way. Diabetes is no different, often the result of years of bad lifestyle choices that can come back to haunt us. And yet, Americans are still ignoring the dangers of diabetes. We’ve decided to take a literal “sit down” stance on the issue. If it ain’t broke, why fix it?
As a disease, diabetes is nothing new. It’s described in historical documents across ancient societies. The earliest Egyptians recognized the ailment. Ancient Indians dubbed it “sweet urine disease” — if ants were attracted to your urine, you suffered from it. In Greek, diabetes means “to pass through,” a nod to its chief symptom of frequent and excessive urination.
We know diabetes today as a chronic metabolic disorder — basically, a malfunction in the critical process that feeds our cells. It comes in three primary forms. Gestational, which only affects pregnant women, and Type 1, which affects just 10 percent of diabetes sufferers when the pancreas produces no insulin at all, are less common. It’s Type 2 diabetes, representing 90 percent of cases worldwide, that’s causing the most damage. Originally called “adult onset diabetes,” the condition started showing up in kids — prompting the name change — when their lifestyles, too, started to cause the chronic condition.
Diabetes, in many cases, is easily treated and manageable. Untreated, it whittles away at anything and everything it can.
Williams has Type 2 diabetes, and his failure to understand and treat it led to his body’s collapse. Our bodies break down what we eat into glucose, a sugar in our blood that acts as our primary fuel source for energy. Glucose is guided through our bloodstream and into our cells by insulin, which the pancreas secretes. After we eat, the pancreas releases enough insulin to regulate the amount of glucose coming in, regulating our blood-sugar levels.
But in a person with diabetes, the pancreas fails to create enough — or any — insulin, so our cells reject the glucose. It then builds up in our bloodstream, eventually passing through our urine but not entering cells to create essential energy.
The body is essentially being continually deprived of what it needs to run well.
Insulin resistance acts as the precursor to Type 2 diabetes and represents a “calorie overload state” in which certain body and muscle cells are storing too much fat. With too many calories coming in, insulin can no longer be stored in these cells, glucose builds up in the bloodstream, and the pancreas burns out. Without regulation, blood-sugar levels skyrocket and Type 2 diabetes sets in.
In Williams’ case, Beard says, he was a “walking candy bar.” Williams also didn’t understand the nature of his affliction, to the point where, in order to urinate, he thought he had to keep his blood-sugar levels high. Medically speaking, it made no sense whatsoever. Beard says Williams also “believed that his nervous system was so reliant on sugar that the insulin would actually cause him further discomfort.”
BEHIND THE NUMBERS
In 2011, diabetes was the sixth-leading cause of death in Michigan. That’s more than 8,500 deaths — one of the highest rates in the country. When you factor in its complications — heart disease, stroke, kidney failure, neuropathy, and amputation — it’s the leading cause of death in the state. An estimated 10 percent of Michigan’s population — about 760,000 — have been diagnosed; another 250,000 go undiagnosed. And since 2001, the prevalence of diabetes has gone up 40 percent among Michigan’s adults.
African-American and Hispanic adult populations are twice as likely as their white counterparts to suffer from the disease. Many are diagnosed late, after complications have taken hold.
The numbers don’t come cheap to Michigan’s health-care costs. At least $8 billion was spent to treat diabetes in 2011.
Nationally, diabetes is the seventh-leading cause of death. Nearly 26 million Americans have diabetes; nearly 7 million go undiagnosed. A recent American Diabetes Association study pegs the total economic burden for diabetes at an estimated $245 billion in 2012. This number is estimated to double in less than 25 years. Obesity, blindness, heart attack, stroke, amputations, and other factors all play a role. On a national level, Michigan stands out. Genesee and Wayne counties boast higher than average rates overall than other metro areas in the country, according to the Centers for Disease Control and Prevention.
Michigan isn’t alone. Arkansas is tied with us for 13th in the country for the highest rate of adult diabetes. Only one day after an appeals court denied a ban on large sodas in New York City, a study released in July by the New York City Health Department declared a 33-percent increase in Type 2 diabetes between 2002 and 2012, making it the second-largest killer behind smoking-related deaths. A survey released the same day interviewing over 1,000 pre- and diagnosed diabetes sufferers found that while 76 percent believed they were managing diabetes correctly, only 57 percent were. A similar study conducted in Michigan in 2009 found that only 60 percent of the population in the state had been educated about the disease.
A LAUNDRY LIST OF FACTORS
But for a disease that can be fought off with diet and exercise, how have we jumped off the edge into a national epidemic?
Michigan is the fifth-most obese state in the country. While the rise of obesity has correlated with the prevalence of diabetes over the past 30 years, it’s not the only factor. In fact, we’ve become distracted from the real issues while we worship at the altar of the scale, says Dr. Tom Rifai, medical director for metabolic nutrition and weight management at St. Joseph Mercy Oakland Hospital.
“This environment we know in 2013 is a setup for diabetes,” says Rifai. “Eighty percent of Type 2 before the age of 80 is preventable, but there’s a confluence of issues and factors. The role our culture and lifestyles play can’t be emphasized enough. We’re in a scenario where we have too many excessive energy calories coming in — carbs or fat are in cahoots with each other — in comparison with how much we move.”
Changing our culture, Rifai says, will be like removing a malignant tumor. You have to cut it out slowly and carefully. To change everyone’s diet tomorrow could potentially affect the food supply. If we adopted our daily seven to 10 servings of fruits and vegetables — and 90 percent of us don’t, according to the USDA — Rifai wonders if there would even be enough produce to go around.
Meanwhile, in the office, we’re sitting eight hours a day. When we get home, more sitting. An hour a day of exercise doesn’t hold up to those numbers. Communities with low walkability don’t help. Some neighborhoods don’t even have sidewalks. Vending machines have invaded hospitals and schools. Recess seems like a forgotten relic. Nutrition and physical education in schools face the same threat as music and arts programs — extinction. A culture of suburban helicopter and safety-minded inner-city parents keep their kids inside, helping the childhood obesity rate skyrocket in recent years.
Food portions are increasing. Dessert acts as a fourth meal. Processed foods dominate our plates. You can argue the concept of the ill-defined “food desert” in urban areas, but the density of cheap, high-calorie, fast-food options is fact.
“The major corporations that make up our food industry release these modified products that have people coming back for more,” says Rifai. “These foods have similar effects to drugs like cocaine and alcohol — raising dopamine and endorphin levels. The things that tempt us are so alluring. For some people, it’s pizza. For others, it’s ice cream. But it’s always some combination of low protein, high carbohydrate, fat, and salt health bomb.”
Dr. Edward Gregg, chief of epidemiology and statistics for the division of diabetes translation at the CDC in Atlanta, echoes such sentiments.
“Nationally in the last two decades, we’ve seen steady increases,” says Gregg. “If anything, the increase has been greater in the past 10 years. When we’re looking at this as a population percentage as a nation, state, or even Detroit for that matter, the number of diabetes complications is quite high. It’s a big burden on people, their families, and the health systems that take care of them.”
RACE AND CULTURE
The cultural factors that determine obesity — the diets we eat, the poverty we live in, the cost of healthy foods vs. non-healthy foods, the active or sedentary lifestyles we live — are fueling the diabetes issue, but it’s not entirely to blame.
As diabetes incidents increase across the population, the most dramatic increases have occurred among those with lower education, in lower social classes, and in lower-income communities. That’s not to say they’re the only ones driving it. Still, Gregg says, those disparities are bound to grow greater before they get better.
FLAWS IN THE SYSTEM
Our national health-care system is treating diabetes better, but there are still major flaws.
“There’s a disconnect,” Gregg says. “Our health-care system has learned how to treat and even prevent complications by managing risk factors, but our health system hasn’t learned how to prevent diabetes. We can keep it at bay better, but we haven’t stopped new cases from coming in. At the end of the day, our health-care system is designed to care for disease and not prevent it.” Gregg notes that there’s a slight upswing in educational programs being hosted out of hospitals.
To further confuse things, predatory pharmaceutical salesmen have swooped in. The Federal Drug Administration recently released a warning against over-the-counter cure-all medications.
“People with chronic or incurable diseases may feel desperate and become easy prey,” said Gary Coody, R.Ph., national health fraud coordinator for the FDA, in an official statement. “Bogus products for diabetes are particularly troubling because there are effective options available to help manage this serious disease rather than exposing patients to unproven and risky products.”
Diabetes is a complex disease with life-shattering complications and a frustratingly simple solution — less intake, more exercise. The CDC and the Diabetes Prevention Program has found that if you lose 5 to 7 percent of your body weight and exercise 150 minutes a week, you can reduce your chance of developing diabetes by 60 percent.
FORMING HEALTHY HABITS
Debates rage over the exact role that genetics play in diabetes, but there’s little to analyze when it comes to the merits of education and raising the level of good health habits in the home. And yet, uneducated adults raise uninformed kids. Community programs on a state and national level are hoping to curb the trend.
“We can’t lay all the blame at the feet of obesity,” says Anne Esdale, public health consultant with the diabetes prevention and control program at the Michigan Department of Community Health. “When we say diabetes is tied directly to obesity, people immediately think it’s their fault. Putting that blame on people and populations doesn’t help get them into self-management programs where they can manage their disease.”
Programs in Michigan like the Diabetes Leadership Initiative help spot early signs and symptoms of diabetes in hopes of treating complications sooner. Part of a national program sponsored by the CDC, the Diabetes Prevention Program aims to inform the public of how easy it is to reduce risk with a better diet and more physical activity.
Rifai offers a multidisciplinary program that focuses on the psychology of “lifestyle change, stress management, why we emotionally eat” — a boot camp for diabetics who can’t do it alone. The three-month program comes at an additional charge beyond what your insurance will pick up, but Rifai sees it as the price you pay for “intensive behavior modification.” About 500 patients have been through the individualized program since 2009.
It’s true that the bad foods we pile onto our plates cost far more than the discount price tag that originally lured us in. It’s part of the daily grind that blurs together. Who has the time?
Like addicts, we have to want to change the way we live and the way we eat. But as adults, we buy into the boogeyman philosophy that if we don’t see it, it’s simply not there. That doesn’t work with our health. Diabetes is a silent killer that plays for keeps. Once it’s gone, it’s gone for good.
And no one knows that better than Greg Williams.
LIVING IN TRUTH
The first time Beard visited that apartment in Flint, he saw a photo of Williams in his athletic days — strong, wholesome, healthy. It was a far cry from the version of Williams that Beard found trapped inside back in 2011: a thin, emaciated sketch of the man he used to be.
But it’s an appearance Williams has recaptured more and more every day.
His blood sugar is under control. And after barely being able to string together three months outside of sterile white walls, Williams hasn’t been hospitalized in nearly three years.
“It’s an amazing reversal and a slap in the face to this disease that has destroyed him in many ways,” says Beard. “It really is amazing to see. He’s proud to have overcome his disability. Not everyone can beat it like he has. I see a lot of people unwilling to leave their homes, but he wants to be out there.”
Williams is even considering walking in the Crim with his prosthetics on full display. He doesn’t mind. He wants to share his story with the world — the good, the bad, and the sugar-soaked ugly.
“I was the worst diabetic patient in a lot of ways, but my body recognizes that I’ve been given a second chance,” Williams says. “It’s been a long journey. Diabetes put me to the test. I’m paying the price in a lot of ways, but this is the healthiest I’ve been. It’s a miracle. A lot of people tell me they didn’t think I would be around much longer. They’re surprised I’m still here.”