Insulin in the body

Six or eight times a day, Cristina Chu pulls her glucose meter out of a pocket and pricks her finger. She may be riding the subway, sitting in a meeting, or walking down the street. She doesn't care who sees. If her blood sugar is high or low, she wants to adjust it quickly through the insulin pump attached to her belly.

In the 22 years since she was diagnosed with diabetes, there have been times when Chu saw a ''bad" sugar reading as a personality flaw. Or when she abandoned regular blood testing and ate recklessly. But lately, she has made peace with her diabetes and found a healthy balance.

''I tend to be Type A about a lot of other things, but with diabetes, doing that is setting yourself up for failure," said Chu, 33. ''The more you freak out, the more it goes to either extreme. You have to give yourself a break."

Chu's attitude and the latest technology help keep her average blood sugar level near an optimal 6, which new research shows could cut her risk of dying from heart disease in half.

But two-thirds of the nation's 21 million diabetics don't adequately control their blood sugar, according to surveys, putting them at risk of blindness, amputations, kidney failure, heart disease, and early death. Surveys of Type 2 patients show that diabetics' control of their blood sugar has declined since the early 1990s and is worse among the poor and members of minority groups. In Massachusetts, nearly 30 percent of diabetics allow their blood sugar to reach dangerously high levels, according to a 2005 study.

The roadblocks are not only psychological. There is the fear of lowering blood sugar too much, a condition called hypoglycemia, which can have severe consequences for children. There is the pain of frequent needle-sticks to test sugar. And there is the pervasive American culture of excess, which is feeding an epidemic of obesity and diabetes.

While few diseases require as much self-care and self-control as diabetes, solving the diabetes puzzle holds lessons for many other ailments. Specialists say it will require a combination of new gadgets and medicines, such as the inhaled form of insulin approved Friday by the US Food and Drug Administration. But it will also require a change in patients' attitude and behavior driven by much more intensive involvement by health professionals. That, in turn, will require insurers to pay for more face time between healthcare workers and patients.

''It's not going to be a quick fix," said Dr. Howard Wolpert, director of the insulin pump program at the Joslin Diabetes Center.

Diabetes consists of two different but related conditions. In Type 1, which is believed to result from genetic defects and typically surfaces in childhood, the pancreas doesn't make any of the insulin needed to move blood sugar into cells to provide energy. In Type 2, which accounts for 90 percent of diabetes and most often develops in later adulthood as a result of obesity and inactivity, the body does not produce enough insulin or can't use it properly. Type 1 diabetics need to take insulin daily through injections or a pump, while Type 2 patients may be able to control their insulin levels through diet, exercise, and pills.

Without adequate insulin, blood sugar levels spike, causing extreme thirst, hunger, and tiredness and eventually damaging the heart, blood vessels, eyes, and kidneys.

The difficulty of managing blood sugar levels was highlighted in a recent study that found that tight control cut heart disease in Type 1 diabetics. The study, published last month in The New England Journal of Medicine, aimed to get patients' average blood sugar levels, measured by hemoglobin A1C, a calculation of blood sugar levels over time, down to 6, but they averaged 7. When the study ended, their blood sugars rose to more than 8.

''These people got the best diabetes education that money can buy, and after the study their control lapsed," Wolpert said. ''Simply educating people is not enough."

Group doctor's visits, classes, and telephone-based support are among the techniques being used to help diabetics.

''We are bombarded every day with high-calorie foods. Liter bottles of Coke cost a dollar. Big bags of potato chips cost very little. We need behavior modification, with lots of repetition and reinforcement," said Dr. Caroline Apovian, director of the nutrition and weight management center at Boston University Medical Center.

But most health insurers don't cover the full cost, making it a money loser for doctors and hospitals.

Technology is being developed to help diabetics avoid blood sugar extremes -- hypo- and hyperglycemia -- and allow patients to live more normal lives.

In addition to inhaled insulin that will end the need for shots for some diabetics, newer insulin pumps link directly with the sensors, making insulin management easier. Continuous glucose sensors are being tested that would provide a reading every 10 minutes when implanted under the skin. If successful, they could end the need for finger-sticks and help keep blood sugar more level.

Robots being tested at the Massachusetts Institute of Technology, Apovian said, follow individuals and provide advice on choice of food and exercise. ''It's like a friendly little pet who's sad when you don't exercise or when you go to McDonald's."

Meanwhile, new medicines are helping control Type 2 diabetes. They stimulate the pancreas to generate more insulin and may also control appetite.

The goal is to make the entire system automated and painless, but that is probably a decade off, said Dr. Martin Abrahamson, medical director of the Joslin.

In the meantime, technology such as the insulin pump helps a motivated patient, like Chu, who has Type 1 diabetes.

She uses a pump the size of a microcassette recorder, which holds a container of insulin and connects with a long thin tube to a needle in her belly. She wears the pump round-the-clock, tucking it in a pocket or, occasionally, in her bra. The pump continuously delivers a low level of insulin -- similar to what healthy people have in their blood all the time. She tests herself before and after every meal and when she feels that her sugar is off. After the test, she punches her blood sugar levels into the pump and, based on a formula she's previously entered, the pump computes how much insulin she needs and delivers it through the needle.

''Sometimes I feel like a bionic person," said Chu, an architect from Lexington who is currently on a Fulbright Scholarship in Spain. ''But the pump gives me a lot of flexibility. When I exercise and can't eat until later, it's not a problem. I can change the insulin intake. I can allow myself to have something sweet."