At the Diabetes Center, Chris Saudek checks up on a patient who has an experimental, implanted pump. "It's a halfway step to the completely artificial pancreas."

One hundred years ago, physicians didn't understand much about diabetes. Even the foremost clinician of the day, Hopkins' own William Osler, used to tell his students that there was really only one thing that could limit the progress of diabetes: opium.

But back then, hardly anyone had diabetes. Today, the opposite is true. While much is known about how to treat and prevent diabetes, it now affects more than 17 million people in the United States alone. Another 16 million Americans test with higher-than-normal blood glucose levels, putting them in a new category known as "pre-diabetic." Diabetes is rampant: If you don't have it yourself, chances are you have family, friends and co-workers who do.

Here at Hopkins, a host of clinicians and scientists are working to solve some of diabetes' most intractable problems. The disease develops when the body is unable to produce or respond to insulin, the vital hormone that allows the sugar glucose to enter and fuel the cells. It affects people of all ages, from grade-schoolers to centenarians. It blinds. It causes kidneys to fail and limbs to be amputated. It sends people into comas. It leads to heart disease and stroke.

And while type 1 diabetes, in which the body completely stops making insulin, generally begins in childhood and is largely unavoidable, the far more common type 2 diabetes has a lot to do with how people live. "It's a side effect of prosperity," says endocrinologist Christopher Saudek. "As people in Third World countries lead a less active and less nomadic existence, diabetes develops. Now, it's reached epidemic proportions, and it occurs everywhere, from China to East Baltimore."

Saudek should know. As past president of the vast American Diabetes Association and member of countless scientific panels and medical organizations, he's seen firsthand the sweeping grasp of this once rare condition. As ADA president, he campaigned to raise public awareness about diabetes' prevalence, its link to heart disease and stroke, and the importance of good care and prevention. When a major clinical trial revealed that proper eating habits and exercise can delay type 2 diabetes, he spread preliminary findings nationwide. (The trial, the Diabetes Prevention Program, is being conducted at 27 medical centers, including Hopkins, where Saudek is principal investigator.)

Saudek directs the Johns Hopkins Diabetes Center, a clinic and patient education program he founded in 1984 (see sidebar). An affable, enthusiastic man who sails and plays the clarinet, Saudek is also a researcher who is interested in all aspects of diabetes. "But my roots," he says, "are in the clinic. It was my patients who kept me grounded when I was president of the ADA. It's fascinating to try to find the triggers for each person struggling with this disease. Some simply don't understand that diabetes is serious-that it can lead to complications like blindness, kidney-failure and amputations. Others know these things but need encouragement. They don't need to be scared."

Saudek's research has long focused on the development of an artificial pancreas, the logical next step, he believes, to the external insulin pump, which has been available for at least 15 years. The external pumps deliver insulin into the body in precise amounts at pre-programmed times through a plastic tube and flexible needle inserted beneath the skin. The artificial pancreas will go even further.

Designed for type 1 diabetics, it will consist of an implanted sensor, an information processor and a small pump that infuses insulin into the body. Diabetics won't have to worry about injections or pricking a finger several times a day for a blood test, because the artificial pancreas will automatically measure blood glucose and continuously deliver the correct insulin dosages night and day. The stumbling block, Saudek says, has been the sensor. "You have to link it to the delivery system, and that's been very difficult."

One portion of the artificial pancreas-the implantable pump-is currently in clinical trials and awaiting FDA approval. The pump is inserted into the abdomen and replenished every three months with insulin. It is not, however, a fully automatic, artificial pancreas, for diabetics must still check glucose levels and activate the pump. Still, Saudek's patients who have the experimental pump swear by it. He's convinced that it should be made available as a product even without the sensor element. "It's a halfway step to the completely artificial pancreas. We just haven't taken that last step yet. But it will be done."

There are similar, significant developments on the horizon. Diabetes may be on the rise, but so is the research with all its life-saving potential. "There is a rising tide of diabetes research," says Saudek. "I am convinced that we are riding an incredible wave of scientific progress that, if taken at the flood, could cure diabetes."

-Anne Bennett Swingle

Finding Help with Diabetes Kathleen Weaver at the Diabetes Center in JHOC: "People should sign up for a one-day course the minute they are diagnosed. She never got sick and had no symptoms-or so she thought. Her vision sometimes blurred, but she chalked that up to hypertension. She was often tired, but with her full-time job, college classes and volunteer work, who wouldn't be? A simple lab test was all it took to confirm one life-altering fact: Kathleen Weaver had diabetes. In one sense, the 53-year-old administrative assistant in the Office of Communications and Public Affairs was lucky. Her glucose levels weren't all that high. Unlike 40 percent of diabetics, she would not have to inject herself with insulin and could manage her condition with medication. She would, however, have to monitor her blood glucose up to four times a day in the beginning. She'd have to exercise more and improve her diet. "Suddenly, information was coming from everywhere," says Weaver. "It was overwhelming." Last summer, Weaver enrolled in the five-day education program at the Johns Hopkins Diabetes Center. The Center operates with a full complement of Hopkins diabetes experts-endocrinologists, nurse educators, dietitians, pharmacists, physical therapists and the like-and offers an array of outpatient programs geared to help people live well with diabetes. Weaver found herself among a group of 10, all in varying stages of the disease. On the first day, she received a thorough, personal assessment. Then she learned about the disease process, nutrition and diet, insulin and oral medications, complications, and the importance of record keeping, physical activity and changing behaviors. The big, take-home message for Weaver was the importance of monitoring food intake and glucose levels and being aware of how the two work together. "The course," she says, "capsulized all the vast ocean of information I had been dealing with." These days, her diet is improved, and to better concentrate on her health, she's cut back on activities. Still, apart from her full-time job at Hopkins, Weaver is earning a bachelor's degree in social work, she's active in her church, she volunteers as an advocate for the homeless and single parents, and even sells cosmetics. So there's more work to be done. "My doctor has told me that if I would only exercise and lose 20 pounds, I could go off medication," she says. "There's a 'duh' involved in this. I see double amputees in the clinic. What better lesson is there than that? I know my lifestyle has to change. There's so much I want to do-and I need to be well to do it."