A Diabetic Looks at Kidney Disease - As a Diabetic, I Have Researched the Complications

I take my kidneys for granted. Most of us do. But these two small organs are unbelievably important. And once they're damaged, it's hard to imagine how your quality of life can decline.

For people with diabetes, the risk for kidney (renal) problems is even higher. According to the Centers for Disease Control's Diabetes Surveillance System, the number of people who began treatment for kidney failure attributable to diabetes increased 485 percent, from 7,000 in 1984 to 41,000 in 2001.

Researchers from the World Health Organization report that in 1995 there were 135 million people with diabetes; by 2025 at least 300 million will have it. Obesity is a contributing factor. With obesity comes increased risk for many diseases, most of all type 2 diabetes, coronary artery disease, hypertension and arthritis. And diabetes and hypertension increase risk for kidney disease.

In 2000, care for patients with kidney failure cost the United States nearly $20 billion. The U.S. Renal Data System researchers forecast that by 2010 the cost in just the United States for ongoing ESRD (End Stage Renal Disease) programs will top $28.3 billion.

Researchers at the Center for Biomedical Engineering report that as of July, 2001, over 1.1 million patients worldwide were on dialysis treatment; they anticipate the number will double by 2010. In the U.S., the total annual cost per patient is about $66,000. The worldwide cost of treating ESRD will surpass $1 trillion for the first decade of the 21st century.

There is a pattern. Obesity is a significant part of that pattern. Proper diet and exercise under a doctor's supervision can help hold off the more serious aspects of diabetes and renal failure in most people. But, make no mistake about it ... obesity is a factor. According to the American Diabetes Associations' statistics from 2001, there are more than 18.2 million Americans with diabetes, but nearly one-third are unaware that they have the disease. The National Kidney and Urologic Diseases Information Clearinghouse estimates that each year, nearly 100,000 Americans are newly diagnosed with kidney failure. More than 100,000 currently have ESRD due to diabetes.

According to the U.S. Health and Human Services Agency for Healthcare Research and Quality, an estimated 650,000 Americans will have kidney failure by 2010 and will require renal replacement therapy, either ongoing renal dialysis or a kidney transplant. Without one of these therapies, ESRD is fatal.

According to the ADA, diabetes is the leading cause of ESRD...which develops slowly, over years, and is often silent. The kidney's tiny nephrons, which act as filters to remove wastes, chemicals, and excess water from the blood, become damaged by chronic high blood sugars.

According to the National Kidney Foundation, new evidence suggests that the incidence of irreversible kidney failure may be about the same for both type 1's and type 2's.

Approximately 43 percent of new cases of ESRD are attributed to diabetes, double in the past 20 years.

In 2000, 41,046 people with diabetes initiated treatment for end-stage renal disease, and 129,183 people with diabetes underwent dialysis or kidney transplantation.

Although diet, exercise, and medications help control blood glucose, diabetes often leads to nephropathy and kidney failure.

American minorities are more likely to suffer from diabetes and kidney failure. The incidence of reported ESRD in people with diabetes is more than four times as high in African Americans, four to six times as high in Mexican Americans, and six times as high in Native Americans than in the general population of diabetes patients.

About 95 percent of people with diabetes have type 2 diabetes. Type 2's are either insulin resistant or produce insufficient insulin, and 80 percent or more are overweight. The American Obesity Association notes that obesity may be a direct or in-direct factor in the initiation or progression of renal disease.

Between 1993 and 1997, more than 100,000 people in the United States were treated for kidney failure caused by type 2 diabetes.

People with type 2 diabetes are not diagnosed, on average, for five to six years after getting the disease, and by that time damage has often occurred -- damage to the tiny capillaries in the eyes, the nerves in the foot, and the vulnerable nephrons in the kidneys. Having diabetes does not mean you'll automatically have kidney failure, but your risk is greater. There are some things you can do:

1. Getting to a healthy weight is important. Depending upon your insurance coverage, consults with a registered dietitian for chronic kidney disease may be covered, or may be reimbursable.

2. If you feel you are high risk for kidney problems...due to diabetes or obesity or hypertension, for example...see a doctor. Doctor consults for renal disease are covered by Medicare, so speak with your physician for a referral.

Why are your kidneys so important? The National Organization for Renal Disease describes the kidneys as our "internal filters," cleaning our system of wastes through urine produced in the million nephrons in each of our two kidneys. Kidneys are also responsible for hormone and electrolyte balance. As they filter out waste, they also regulate sodium and potassium, and release hormones necessary for red blood cell production, to maintain calcium levels and regulate blood pressure.

When kidneys lose their ability to filter out wastes, a person must have the blood mechanically filtered, or get a kidney transplant. The process of dialysis is time consuming and may be uncomfortable; also, the patient must follow a strict diet and medication regime. Transplant means permanent treatment with anti-rejection drugs.

There are other causes of kidney failure besides diabetes: trauma, genetics, and environmental toxicity such as poison could also damage the kidneys. But, diabetes is the number one cause of renal failure, so take charge to reduce your risk. Intensive blood glucose control slows the progression of kidney disease.

1. Work with your doctor to maintain normal blood glucose, by testing often and administering insulin based on diet and exercise.

2. Have your doctor measure your A1C level at least twice a year. The test provides a weighted average of your blood glucose level for the previous three months. The ADA says aim for A1C of 7

percent or less.

3. Have your urine albumin excretion (protein in urine, a sign of kidney damage) checked at least once yearly. This was the test that caused my doctor to first suspect diabetes in my case.

4. Check your blood pressure regularly. Hypertension is a double edged sword. It contributes to kidney disease, and it's caused by kidney disease. The American Diabetes Association and the National Heart, Lung, and Blood Institute recommend that people with diabetes and kidney disease keep their blood pressure below 130/80.

5. Obesity increases risk for hypertension and type 2 diabetes: losing weight helps lower blood pressure and increases insulin sensitivity.

6. Ask your doctor whether you might benefit from taking an ACE inhibitor or ARB. People with kidney disease should consume the recommended dietary allowance (RDA) for protein, and avoid high-

protein diets. It's extremely important to reduce your dietary sodium and phosphorus if you have renal disease. A reduced protein diet with advanced kidney disease may help delay progression.

However, people on dialysis have different needs and requirements, and may need more protein. Dialyzed patients will work with a registered dietitian to achieve the optimal balance depending upon their type of treatment.

The forgoing is not intended as a substitute for a physician's advice, and should not be applied as such. For additional information, I suggest the Joslin/Harvard Medical site http://joslin.org/LearnAboutDiabetes_Index_home.asp

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Obesity Is A Social Contagion, Say Experts - Could Texas Be Spreading The Disease Of Fat?

Obesity is spreading like a virus -- literally. According to recent analyses of thousands of participants over three decades, you're more likely to get fat if your friends do. Looking at obesity as a sort of social contagion may even help explain why the weight of America's residents has suddenly ballooned over the last generation.

Sound farfetched? Well, not according to Nicholas A. Christakis, physician and professor of medical sociology at Harvard Medical School, and a principal investigator of a study published in the New England Journal of Medicine that tracked a large social network of 12,067 people between 1971 and 2003. Unlike most studies of its kind, which only record the relationship of an individual and his/her contacts, the Framingham Heart Study looked at a network, practically tracking the entire town of Framingham, Massachusetts, and each participant's social contacts.

Studies like this could be especially important to Texas, where obesity has become a major health problem. Sixty-one percent of adults and 35% of children in the state are considered obese, and it's not just a cosmetic problem. The condition is a serious medical issue, and can lead to heart disease, type 2 diabetes (also at epidemic levels in Texas), stroke, and even certain cancers. In a state where 25% of the population is going without health insurance, and the health care systems are already overburdened -- particularly in the larger cities of Dallas, Houston, and Austin, where rural residents come seeking care -- any increase in disease could effectively collapse the system.

The Framingham study was actually a large federal study intended to investigate heart disease. Every four years, each subject was examined and asked to name at least one person who would know where he or she would be at the time of the next evaluation. As most of the town and its relatives participated in some fashion, a large social network was tracked and data, such as weight and body mass index, recorded. Investigators knew each participants' relationships with each other -- be it sibling, spouse, neighbor, or close friend.

Analysts concluded that an individual was 57% more likely to become obese when a close friend did. In fact, friends had more influence on each other than family. Statistically, there was no effect when neighbors gained weight, and close mutual friends had the most affect on each other, even if they were hundreds of miles apart. If one became obese, the other had a 171% chance of following suit. The same effect was noticed for weight loss, but as Americans have been predominantly growing fatter, an increase in weight was seen more often.

If the idea of likening obesity to a contagious disease seems harsh, perhaps it is, and, according to Christakis, he and colleagues are not intending to blame the patient for the disease so much as to determine why the epidemic is occurring. One explanation for the dramatic increase in American poundage is that an obese person is likely to influence another in his or her social network (i.e., a friend) to also become obese, in the same way that an individual losing weight might. Friends may also affect each other's perception of fatness, and what weight is acceptable. "...[the effects] highlight the importance of a spreading process, a kind of social contagion, that spreads through the network," said Christakis.

While Richard M. Suzman, from the National Institute on Aging (which funded the study) hails it as "one of the most exciting studies to come out of medical sociology in decades," colleagues like Kelly D. Brownell, director of the Rudd Center for Food Policy and Obesity at Yale University, aren't so sure. "I think there's a great risk here in blaming obese people even more for things that are caused by a terrible environment," said Brownell.

Further, no one disputes the influence genetics have on the condition. An individual generally has a genetically predetermined weight range, usually around thirty pounds. The environment, then, can play a major role in determining whether a person is near the bottom or top of that range. With all the advertisements for heavily processed, sugary, and high-fat foods that are cheaper than healthier produce, it's easy to see how "environment" can be a negative influence, indeed.

The Framingham review is unique, which can be seen as a rare and tremendous breakthrough, as well as a study that's difficult to replicate -- an important aspect in determining its overall scientific validity -- according to Stephen O'Rahilly, an obesity researcher at the University of Cambridge. No other study has the same, long-term, detailed analysis of a population and its social networks, and it could take another thirty-two years to produce one. Its results are telling, and something to consider. How much do we influence each other, and not realize it? If we can encourage our friends to gain weight simply through our own attitudes and habits, then can we, instead, encourage them to be healthier? Viewing the results as an opportunity to be aware of how much we can influence each other to do better, or as just highlighting another factor working against us, is really a matter of perception.

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