A white-haired woman in a wheelchair, speaking to her husband by the wall, is missing both legs. A middle-aged man who had his lower left leg sawed off pushes past on the right. An attractive woman with long dark hair – she can't be more than 35 – wheels through a door on the left. Her right leg is missing.

There's also Manfred Nothlich, age 51. He is a lead baggage handler and de-ice co-ordinator at Pearson airport; a proud father of three, including a daughter who recently graduated from high school. He is also a wounded soldier in the vicious war on diabetes that is sweeping the globe.

An estimated 850,000 people are diagnosed with diabetes in Ontario – including one in nine adults in Toronto – and the numbers are growing. So, too, are the numbers of people with crippling and life-threatening complications that come with the disease: heart attack, stroke, kidney failure, blindness and amputations.

Nothlich is doing the wheeling while we take up the rear, acutely aware of our good fortune to be walking on two legs.

The 21 amputee rehabilitation beds at West Park Healthcare Centre in Toronto are always full. Eighty per cent of the time they're occupied by people with diabetes.

Today, one in 10 hospital beds is taken up by a person suffering one or more complications due to diabetes. Perhaps most disturbing is that the overwhelming majority suffer from type 2 diabetes, considered preventable by diet, exercise and not smoking.

For medical experts, the prospect of the disease going unchecked into the future is alarming. They say the province can keep pouring money into management of diabetes patients and treatment of complications, but sooner or later the big push has to target prevention.

Last year, the Toronto-based Institute for Clinical Evaluative Sciences, an independent research organization, was buoyed to find that the rate of hospital admissions for heart attack and stroke, as well as death rates, due to diabetes had fallen over the last decade. "That was encouraging," recalled Toronto endocrinologist Dr. Gillian Booth, a researcher on the study. "But when you looked at the actual numbers of people with diabetes being hospitalized and having complications, the numbers were so staggering."

The ICES team discovered not only were the numbers of new cases rising in Ontario, but a 25 per cent decline in the death rate meant people were also living longer, with complications that could one day overwhelm the health care system.

That, said Booth, set off alarm bells over the urgent need to act to stop the rise in numbers of people getting the disease in the first place. In Toronto alone, 50,000 more adults have been diagnosed in the past four years.

Today, 40 per cent of people treated in Canadian dialysis clinics for kidney failure suffer from diabetes, up from 25 per cent a decade ago.

One-third of heart attack patients are diabetic. And in Ontario 70 per cent of lower limb amputations, other than for trauma, involve people with the disease.

Prevention can mean a host of things, from providing universal access to excellent health care to making sure the poor have enough money to eat healthy food. But will governments steer money away from those suffering now into measures that may see no return for decades to come?

Nothlich makes a sharp left, then right and steers into the hospital gym where he begins a round of exercises to strengthen his upper body and practise walking with a prosthetic. He is still wobbly and needs the parallel bars to balance.

Never in his wildest dreams did he imagine he'd be spending the weeks leading up to Christmas recovering from the loss of a leg. Certainly not as the result of his diabetes.

It happened so fast. One day he had a callus under his small toe from a new pair of boots. It became infected, so a doctor prescribed antibiotics. The medication didn't work so another type was prescribed. Days on, he noticed one of his toes turning black and drove straight to his local hospital.

"The surgeon came up and basically cut it, carved it off like a turkey. I didn't feel a thing," he recalled. Less than five days later, surgeons had to cut his right leg off above the knee in what amounted to a life-saving operation.

What went wrong? is a question that Nothlich can't answer with just one explanation. He blames a lifetime of unhealthy eating habits; his smoking; years of shift work that played havoc with trying to keep blood sugar levels under control; stress; living alone with no one else to cook for.

"Twenty-twenty hindsight is cheap," Nothlich says. "Right now I'm just taking it day by day."

Diabetes, for years considered a relatively benign illness, can wreak havoc on the body if left untreated and poorly managed. Those who get it do not suffer symptoms for years, which explains why so many ignore their doctor's advice to change their habits. Eventually abnormally high blood sugar levels damage large and small blood vessels, leading to long-term and life-threatening complications.

At some point, all people with diabetes will develop one complication or another, but major studies have proven that tight control of blood sugar lowers the risk of kidney disease, blindness and amputations that so adversely affect one's quality of life. Control of blood pressure and cholesterol levels have also been shown to reduce the risk of heart disease.

"The issue is which complication and the timing of it," said Karen Philp, national director of public policy for the Canadian Diabetes Association. "If you can delay the complications you're better off and your family is better off. And if you can stay home and be healthy, you can also make the wait times for surgery shorter."

The association has been pushing for better treatment of diabetes and this fall the Ontario government committed $450 million over four years to tackle the disease and its complications. A registry will be set up with a goal to identify all people with diabetes and give them access to health and education services. More diabetes education clinics are planned. Better co-ordination between doctors and other health professionals are promised. There's even the prospect of the government extending its coverage of the cost of insulin pumps from children to adults.

But how these plans will reduce diabetes complications remains to be seen. The problem is while diabetes may be easy to diagnose, it is one of the hardest illnesses to manage.

Keith Walton is 56, and has operated his own towing business for 27 years. Like Nothlich, he also lives alone except on weekends when his girlfriend comes down from Barrie to visit and cook some healthy meals. For now, he's sharing a room with another diabetic amputee at West Park hospital, with a window overlooking a picturesque ravine.

He'd like to believe better health care and education will help others, but he's not so sure.

"I tried to do what I could," he said, recalling the doctor's and dietician's messages to go easy on the fast-food joints, curb his soda pop cravings, and keep his blood sugar in check while on the road. He was diagnosed 15 years ago.

"I didn't take it very seriously in the beginning. I was working crazy hours and when I needed to eat I'd pull in somewhere for a quick burger. Later on, when I had to go on the needle, I wouldn't have it with me for an injection. When I did start watching my sugar levels, a lot of the damage had already been done."

Today, he has three toes missing from his left foot, his lower right leg is gone, he has hardening of the arteries and his kidneys are operating at half their capacity. He also runs a much higher risk now of losing his other leg.

"It's a huge burden on people," said Booth, which is why diabetes specialists and family doctors need to find the time to help people self-monitor in ways that work best for them.

Ultimately, of course, there are those stuck with the costs, which can range from $1,000 to $15,000 a year depending on an individual's health coverage. There's the insulin pumps, the tubing, the glucometers, the needles, not to mention the blood sugar level test strips that cost a dollar a pop.

Dr. Kevin Moran, a Toronto family physician who has type 1 diabetes, sees it all the time in emergency rooms, people whose blood sugar levels are shooting through the roof and "you start talking to them and find out they don't test (their levels) regularly. You ask them why and they say the test strips are expensive. That's their straight-up answer. And yet that's one of the things to reduce the risk of complications."

He doesn't buy the excuse that shift work or long hours prevents someone with diabetes from keeping it under control. "It's as if you didn't bring your car keys with you. I go to work on the night shift, I bring my snack, my insulin, my glucometer. You just look after it."

Three-quarters of Ontarians with diabetes are monitored by their family doctor, but Moran believes diabetes education clinics can do a better job. Wait times to get in are long – three to four months in Toronto and up to a year in more remote parts of Ontario.

Despite the push for more education teams, more clinics and self-management classes, York University sociology professor Dennis Raphael says even the best health care won't help those most at risk of diabetes and its complications.

The prevalence of type 2 diabetes has been repeatedly linked to poverty worldwide, as are its complications. In Ontario, the 2003 ICES Diabetes Atlas study found low-income people were more likely to develop serious complications, like kidney disease, than those of higher incomes. First Nations people are three times more likely to have life-threatening complications.

"Even with the best medical care, their living circumstances make it virtually impossible for them to be carrying out the activities we know help manage it," said Raphael. "If people have no material resources they have no lives."

He refers to his ongoing study of 60 people with diabetes who are living on welfare or disability in downtown Toronto. These are people who are more concerned about where they grab their next meal than how that meal will affect their blood sugar.

"They know what they're supposed to eat," Raphael says. "They take their blood counts, they pull these booklets out that they've been given, they know of complications. They intellectually know all this stuff. I say, `Well, how do you manage your diet?' The guy laughs. `Manage my diet?' he says. `It depends what they're serving at All Saints Church for lunch.'"

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