When her grandfather died in 1992 from a sudden heart attack, Joyce Malaskovitz went through the expected sadness and grief. But she also recalled memories as a child, those of him checking his urine for sugar and using special tablets to sweeten his coffee. Malaskovitz’s grandfather was a diabetic, and these moments clearly made an impression on her.
“I started my career right out of college in the diabetes field in 1981 to learn as much as I could to help him manage his diabetes and to stay healthy,” Malaskovitz said. “I was 33 at the time he passed away and have devoted my entire nursing career to the field of diabetes.”
She also remembered there wasn’t a lot of discussion about diabetes when she was growing up, even among those who had it. Today, as the director of health and wellness at Desert Springs Hospital and Medical Center, she oversees its inpatient and outpatient Diabetes Treatment Center. In her role, she isn’t quiet about the disease and the many advances that have been made to help people learn to live with it.
“I remember back then you didn’t talk about it too much. It was sort of hush-hush. When I started (in nursing) 50 percent of the people didn’t even know they had diabetes,” she said.
The program Malaskovitz oversees is the first of its kind in the valley — an inpatient and outpatient diabetes care offering with accreditation from the American Diabetes Association, the American Association of Diabetes Educators and a Joint Commission accreditation for its outpatient component . The treatment center offers plenty of free education opportunities and discounted services to help diabetes patients keep their blood sugar under control.
But more important there is peace of mind in knowing the program makes Desert Springs a facility that is “diabetes friendly,” no matter what type of procedure a diabetic or prediabetic patient is undergoing, Malaskovitz said.
“We have diabetes experts, clinicians and all the physician specialties are trained on diabetes,” she said, while also talking about the program’s popular educational classes. “We want to provide support. We want to be a phone call away when patients decide they just can’t deal with it anymore.”
According to the Diabetes Association, 25.8 million Americans have diabetes, or 8.3 percent of the U.S. population. Seven million of those are undiagnosed. The financial effect of the disease is huge. Diabetes is responsible for $176 billion in direct medical costs annually and $69 billion in lost productivity, according to the association.
As many already know, diabetes is a chronic disease involving high levels of sugar, glucose, in the blood. The body’s pancreas produces insulin, which moves glucose from the blood into muscle and other areas of the body for energy and proper function.
There are two types of diabetics: Type 1 and Type 2. Type 1 often, but not always, occurs in childhood. A Type 1 diabetic’s pancreas produces little if any insulin and the sufferer requires insulin injections for life.
About 90 percent of diabetes cases, however, are considered Type 2, sometimes referred to as adult-onset diabetes. In these cases, insulin regulation is compromised because the pancreas has been forced to produce more insulin than normal for a long period of time. Eventually, it can no longer produce enough, causing swings in blood sugar levels.
A diabetes diagnosis comes when a fasting blood glucose test (also known as an AC-1) reads above 126 mg/dl (milligrams per deciliter). But those whose ranges fall from 100 to 126 mg/dl are considered to be in a prediabetic stage. Estimates widely range for how many Americans are prediabetics; some are as conservative as 40 million, others as high as 70 million, leaving the door open for more diagnoses in the future.
Malaskovitz also said it is important to dispel the myth of sugar causing diabetes. Being overweight, she said, is the main cause behind the chronic disease. Fat cells, by their very nature, do not use insulin efficiently.
“Fat cells don’t see insulin well. So the pancreas needs to put out more of it,” said Dr. M. Fariba Rahnema, head of Valley Endocrinology.
Signs, symptoms, complications
Excessive thirst, frequent urination, fatigue, sudden weight loss, blurry vision and excessive hunger are considered standard diabetic symptoms. Wounds that won’t heal completely can be a sign of diabetes, too, according to Malaskovitz.
Living in the desert can complicate thirst symptoms, the expert added. Sometimes a diabetic will drink abundant water throughout the summer and blame hot weather, only to find he or she is still drinking a lot of water in the fall. That’s when the diagnosis comes.
Severe complications for diabetics include kidney failure, neuropathy, hypertension, blindness, peripheral artery disease and a high risk of stroke or heart attack.
Vascular problems are at the center of diabetes complications. After many years, nerve damage can make it difficult for wounds to heal in the feet. Some diabetics face amputation. Some men will have trouble achieving erections .
“People focus on the heart (complication) a lot, but poor circulation is bad for every part of the body. This is why amputations could occur,” said James Atkinson, a bariatric surgeon and the medical director of the Surgical Weight Control Center in Las Vegas.
Rahnema said she sees more and more teenagers in her practice with prediabetic symptoms.
“I can see it happening. Their neck is thicker. Their armpits are thicker. They may not have diabetes right now, but they will,” she said.
She warns these teens of signs such as a thicker mid section in girls and general inflammation throughout the body. More than usual acne and muscle loss are also signs that a younger patient could someday develop diabetes .
By simply losing weight, a person can put diabetes into remission. Atkinson said his practice has added a medical weight loss program as well. The national rule of thumb of a body mass index of 35 or more allows someone to be a candidate for bariatric surgery. But Atkinson stressed that the focus for his practice is to get the patient losing weight, even before surgery or in some cases avoiding surgery altogether if the weight-loss regimen is successful.
“This is not at all a surgical angle, but if we can do something about the weight problem, that’s the best thing we can do to prevent diabetes too,” he said.
In a normal body, when the pancreas secretes insulin, appetite decreases. This is because of the presence of GLP-1 (glucagon-like peptide) produced by the body’s hypothalamus, Rahnema said. But diabetics tend to be genetically predisposed to showing an absence of GLP-1. In diabetics, the hypothalamus is resistant to making it, which also boosts appetite.
“Diabetics tend to have a ferocious appetite and with this problem (lack of GLP-1) they tend to eat until the stomach has no more room,” she said. “Everything we do is based on our genetic background but that doesn’t mean we cannot change these things.”
Monitoring weight and tracking blood glucose levels in the morning, before going to bed and two hours after each meal are keys to living with diabetes, according to recommendations from the Diabetes Association and other experts.
Beyond weight loss and glucose monitoring, medications can help . Some work to improve cell sensitivity to insulin. Others stimulate more insulin production from the pancreas. Some others work to decrease the release of glucose from the liver. These oral medications include: meglitinides, sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, biguanides and thiazolidenediones.
S ide effects include sore throats, headaches, hypoglycemia (low blood sugar), weight gain, nausea, skin rash and liver disease . What works for one person may not work for another, experts say.
Rahnema also said there is a “new era” of diabetic medicine , some of which not only bring down blood sugar but also help with weight loss. Some new medicines include Exenatide and Bydureon. But some severe side effects are still a concern for this group of medications, Rahnema said, who remains confident the side effects will be eventually eliminated.
The diabetic mind
Diabetics also suffer psychologically. Jillian Inouye, associate dean of research at the University of Nevada, Las Vegas’ school of nursing, is a psychologist who studies how diabetic patients perceive their health as well as their relationship with food. She has learned that many diabetics don’t want to make lifestyle changes. Some of that may have to do with not fully understanding the health information they are given.
“For most of them they get the health education of ‘eat healthy and exercise.’ But they are not given the details and skills on how to do that when they’re on the go and fast food is closer than a home-cooked meal,” she said.
In her research, Inouye studied more than 200 people, half in a group that received a standard form of diabetes health education while the other group was put into a six-week program that included sessions involving biofeedback and relaxation techniques, value clarification work, cognitive restructuring and cognitive intervention.
Part of the program involved talking to patients about how they viewed food. In many cultures sharing big meals is a way to show love, Inouye said. Often, diabetics battling weight problems also view food as a reward or coping mechanism for stress.
Inouye and her team looked to give alternatives to food rewards while shifting the mindset to the enjoyment of other nonfood rewards as well. Depression and anxiety problems can also commonly be seen in diabetics, Inouye added, making it even tougher to overcome the food-for-comfort-and-love culture among many diabetics.
Inouye is finalizing her study’s conclusions after following 200 patients over the course of a year. Early indications show those in the six-week program fared better when it came to sticking to lifestyle changes.
As an endocrinologist, Rahnema is what some call a dying breed in medicine, but arguably one of the most effective practitioners that could help diabetics. The endocrine system is a series of glands throughout that body that produce hormones. An endocrinologist has intimate knowledge of the most flawed gland, the pancreas, which produces the hormone insulin, in diabetics.
But few medical students are choosing the field because it is not considered a big money maker. The median salary in the U.S. for an endocrinologist is $199,893 according to Salary.com. The field comes with high demand, too.
A 2008 analysis published by the Endocrine Society estimates only half the needed number of endocrinologists is in place to serve a potential 25 million to 100 million patients, many of them diabetics. But Rahnema enjoys the field because there is always something new to learn.
“You don’t get bored with the hormones there’s always something new to read,” she said.
The certified diabetes educator field is also growing along with the diabetes epidemic. These positions require a bachelor’s degree and two to four years of experience in the field or in a related area, as well as registered nurse certification. The position involves educating diabetics on lifestyle changes as well as patient monitoring.
The median salary for a certified diabetes educator is $67,963, according to Salary.com. The field’s demand is expected to increase 60 percent by 2025, according to the American Association of Diabetes Educators.