Just as America's diabetes epidemic began almost two decades ago, Georgia Richardson was diagnosed with type 2 diabetes, the potentially life-threatening illness that affects the body's ability to process blood sugar.
"To be honest, I was in denial about my diabetes for a while," she said. "It's as if I thought, 'Maybe it will go away,' even though I knew it wouldn't."
Now 77, Richardson, a retired Sacramento teacher, eventually reduced her weight and began an exercise regimen. But she admits she lost valuable time embracing the necessary lifestyle changes that can help combat the disease.
"We need to look at things people don't want to face," she said, "and diabetes is one of them."
If extending longevity was the signature public health achievement of the 20th century, many experts believe that conquering obesity and type 2 diabetes conditions that often go hand in hand will be the key public health challenge of the 21st.
"It's a largely self-inflicted problem," said Dr. John Bissell, chief of neurology at Kaiser Permanente South Sacramento Medical Center. "And there are huge public health problems as a result."
While doctors also worry about the rise of type 2 diabetes in younger people, an aging country driven in large part by the enormous population wave of the baby boom generation is by definition a country coping with a diabetes problem. Older age is one of the main risk factors for the disease, along with obesity, poor exercise habits, certain ethnic backgrounds and genetic predisposition.
Left unchecked, the diabetes epidemic will result in higher medical costs as well as the threat of shortened life spans for younger generations. It also raises the possibility that for people already 65 and older, their elderly years could become a time of chronic, painful consequences.
Type 2 diabetes is the leading cause of kidney failure, new cases of blindness and amputation for reasons other than trauma. It's a top contributor to high blood pressure, stroke and heart attacks, and has been linked with the development of dementia.
In short, the disease makes older age exponentially more difficult than it needs to be.
"The dementia link is significant," said Bissell, "but I don't think that's well understood by people with diabetes. They have so many other health problems, and they have so many people beating on them about their weight because of those health problems."
Almost 27 million Americans age 65 and older more than one-fourth of that age group have type 2 diabetes, according to the Centers for Disease Control and Prevention. An additional half of all people in that demographic are pre-diabetic, with blood sugar levels high enough to cause concern. While new diabetes cases have soared especially high in the South, the overall national rate has doubled since 1995.
Already, one of every 10 adult Californians has type 2 diabetes, according to California Diabetes Program data, and one of every three state residents is pre-diabetic.
The CDC projects that, without a major public health awakening, one-third of all Americans will have the disease by midcentury.
"We see the effects of the diabetes epidemic every day," said Dr. Kimberly Buss, Sutter Medical Foundation's medical director of diabetes education. "We used to get 100 new cases referred to us every month. Now it's 400 or 500 a month.
"And as the proportion of people 65 and older goes up, the total prevalence of diabetes will increase."
Problems with insulin
Type 2 diabetes results when the body can't produce the hormone insulin or when it has become resistant to the insulin it produces. (Weight and inactivity help create insulin problems, though researchers don't know why.) Without insulin to whisk glucose into the cells for use as energy, damaging levels of sugar build up in the bloodstream.
Many people develop excessive thirst, fatigue, blurred vision, darkened neck folds and other symptoms that lead them to seek help. But many others, like Richardson, have few symptoms before routine blood work provides a diagnosis.
The good news is that unlike type 1 diabetes an autoimmune disorder often with onset in childhood type 2 diabetes often can be prevented by healthy lifestyle habits: walking 30 minutes five times each week and eating a balanced diet.
It's a simple solution to the epidemic. But by the millions, people don't do it.
"We have more sedentary jobs now," said Dr. Debra Bakerjian, a UC Davis Nursing School adjunct professor and president of geriHealthsolutions, a long-term care consulting firm. "We work long hours, and many people commute.
"It's hard to work exercise in there most of us don't have jobs that allow us to be mobile. And with the time crunch, we lean toward fast food."
The consequences are steep. Type 2 diabetes cannot be cured, though evidence indicates weight loss surgery might help reverse it. Generally, with diligence, the illness can be managed, so complications never occur.
Robert McMurry, a 91-year-old retired Air Force colonel who lives at Eskaton Lodge Granite Bay, was diagnosed in 1980. His eyesight remains good. His mind is sharp, and frankly, he doesn't put up with nonsense.
"I've kept the diabetes under control," he said. "The secret word is discipline. You have to eat the right stuff and live a healthy lifestyle. It's a life-and-death decision."
He takes insulin twice a day, but most type 2 patients manage it with a range of diabetes medications that work so well, said Bakerjian, that people often neglect to make the appropriate lifestyle changes.
"They get lazy sometimes," she said. "But being active and mobile will reduce the co-morbidities."
Damage can be stealthy
Consider, on the other hand, the toll of unmanaged blood sugar, beyond amputation, kidney and heart disease and vision problems. Damage to the peripheral nerves which control every part of the body except the brain and spinal cord can cause pain and numbness in the extremities, to the point that people can't walk.
Other people have damage to the nerves of the digestive system; still others, the autonomic system controlling heart rate, blood pressure and breathing.
"The thing about type 2 diabetes is, it's deceptively not scary at first," said Scott Terrell, 55, a utility consultant who lives in Truckee and was diagnosed three years ago. "You may not feel like you're doing real damage, but that's because the early symptoms are mild.
"You can't judge by the level of your symptoms. It's better to be proactive, and you won't have worse symptoms."
In the heart of the local diabetes epidemic at her Sutter clinic, Buss finds that newly diagnosed older patients tend to take diabetes education seriously, even when they're already dealing with other chronic ailments.
"They take their diagnosis as the motivation they need to truly make dramatic changes," said Buss. "It's a catalyst for them. They're just at the point of retiring from work. They have the time to focus."
And since the most devastating complications often take a decade or two to develop, people diagnosed at 65 still have time to prevent the damage.
"We often see folks in this age range really embrace the changes," she said.
Georgia Richardson did, after she got beyond her initial sense of denial.
Now she swims. When it's not too hot outside, she walks. She goes to balance class twice a week, because she's afraid of losing mobility to the mild case of peripheral neuropathy that makes her toes so numb that she sometimes feels as if she's walking on river rocks.
She has arthritis, too, and slightly elevated blood pressure. But she's determined.
"I can't sit and be a rocking chair person," she said. "I just want mobility."