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This year, 17 million people in the United States lived with diabetes.
Hollywood told us about one of them.
Moviegoers spent more than $95 million to see an adolescent Kristen Stewart get locked inside a "panic room," act out hypoglycemia-induced seizures and come disturbingly close to slipping into a coma and dying before receiving a life-saving glucagon shot.
This image sticks in movie patrons' minds almost as vividly as Julia Roberts' 1989 Oscar-nominated depiction of a woman who succumbs to diabetes-related kidney failure in "Steel Magnolias."
An Underused and Inaccurately Portrayed Theme
In the past 20 years, barely more than a dozen movies used the drama of diabetes to draw audiences into a story. Most references were minor. The disease played a more significant role in a few films, including "Steel Magnolias."
Nearly all of them left the impression that diabetes draws the people who suffer from it into an uncontrollable tailspin toward death.
The popularity of "Panic Room" pushed several emotions and questions to the surface. While some decry Hollywood's history of extreme or inaccurate portrayals of people with diabetes, others applaud "Panic Room" and other movies that put diabetes—albeit with a little misinformation or confusion—into mainstream dialogue. Some say such movies can be wake-up calls to the public, and possibly Washington, about how serious diabetes can be.
"Isn't that what the arts are? A portrayal at the edge of the limits?" asks Francine Kaufman, MD, an endocrinologist at Children's Hospital in Los Angeles and current president of the American Diabetes Association. "I think the average reasonable person realizes they're watching a movie. 'Steel Magnolias' showed that diabetes has a significant role in people's lives and sometimes involves loss. It showed diabetes at its most tragic, and that's good for fundraising."
The Worst-Case Scenario
Hollywood's depictions of people with diabetes often have grown out of the need for a dramatic element.
In "Panic Room," the story centers on a divorced woman, played by Jodie Foster, and her young daughter, played by Stewart, who hide in their New York brownstone's secret room (the "panic room") after three burglars break in looking for a hidden cache of money.
The young character, Sarah, has diabetes and experiences an episode of low blood glucose (hypoglycemia) while trapped in the panic room with her mother.
"Without that [element], obviously they could have stayed in there for days if they wanted to," associate producer John Dorsey explains.
A diabetes emergency served the same role in 1997's "Con Air."
A prison parolee, played by Nicolas Cage, and another convict, whom he befriends, are being transported on a maximum-security plane with some of the country's most dangerous criminals. After the plane is skyjacked, the friend, who has diabetes, doesn't receive a scheduled insulin shot, and his syringes are destroyed during in-flight chaos.
Diabetes provided plenty of drama in "Steel Magnolias," too.
Many moviegoers recall Julia Roberts in the movie with beads of sweat on her lip and brow, fighting an offer of orange juice from Sally Field during a severe hypoglycemic episode in Truvy's Salon. It was arguably the most famous scene depicting a person with diabetes in a major motion picture.
"Everyone I knew who saw it said to me, 'Oh, my gosh, when's the last time that happened to you?'" says
34-year-old Kelly L. Close of San Francisco, who has had type 1 diabetes for 17 years. "Being hypoglycemic is one thing, but that kind of thing has happened to me maybe once in seventeen years, and it wasn't even as bad as that. Why show the scariest, freakiest thing? It's backtracking in terms of education. I think that was terrifying for people. It was terrifying for me."
Some found the portrayal of Roberts' character terrifying because, unlike most movie scenes involving characters who have diabetes, it was true.
Originally produced as a stage play, the movie was based on the story of writer Robert Harling's mother and his sister, who had diabetes.
In the story, M'Lynn, played by Field, and daughter Shelby, played by Roberts, are part of a special sisterhood that meets regularly at the local beauty salon in a small Louisiana town. The women become a crucial source of support throughout Shelby's wedding, the birth of her son and her subsequent kidney failure. Shelby dies after a failed kidney transplant using her mother's donated organ.
Harling's sister, Susan, died in 1986 at age 32 of kidney complications.
The material was accurate, but many people with diabetes believe that it was overdramatized or an extreme example of what could happen but isn't common.
"Having any [characters with diabetes] is better than none, but I think there is a danger to overdramatizing," Close says. "I don't think that's progress. Optimally, we can educate in a rational, realistic, progressive and helpful manner."
Katie McGovern also believes that overdramatization can be detrimental.
McGovern, a 27-year-old from Portland, Maine, who's had type 1 diabetes for 16 years, was bothered by the use of diabetes as a "literary convenience" in the 2000 movie "Chocolat." The movie, in which Judi Dench portrays a grandmother with diabetes, reinforced the stereotypical labels of "good" and "bad" people with diabetes, McGovern argues.
"At the end, through the metaphor of chocolate, people are able to embrace a free lifestyle and sexual freedom and reject repression of all kinds. And that wasn't available to the woman with diabetes. Well, it was, but at a price," she says of Dench's character, who dies of complications from diabetes presumably brought on by hanging out in the chocolate shop instead of adhering to a healthier diet.
For McGovern, this implication stung. After 16 years of fairly good control, she's now showing signs of retinopathy.
"I think [Dench's character in 'Chocolat'] reinforced the idea that as long as people with diabetes take care of themselves, they won't get complications, and that could be bad for fundraising. It's just like people thinking insulin is a cure," she adds.
Filmmakers argue that movies aren't made to educate or advocate. Rather, they are stories designed to entertain.
Rick Podell wrote the 1986 screenplay for "Nothing in Common" based on his experience taking care of his late father, who had diabetes.
Jackie Gleason portrays the father, a man who's estranged from his family while grappling with his diagnosis.
Podell recalls that the directors inserted advocacy dialogue into his script that wasn't necessary. He adds that there's such a thing as going too far and including too much information in movies. Good stories, he says, are all about subtlety.
"Advocacy in movies doesn't work," he asserts. "What happens is that audiences sense that. They sense that they're trying to promote something, and it doesn't work. I prefer to just let the characters live. The refusal to go to the doctor, losing eyesight, his feet turning black—that's all self-evident. At least to me."
Vive la Différence!
It's nearly impossible to gather a majority opinion about movies that portray people with diabetes. Part of the reason is rooted in the very nature of diabetes. Not every person is alike, and therefore not every experience is alike. People with diabetes generally juggle insulin or medication, food and exercise of some form to control the disease. People with diabetes and doctors alike will vouch that it's never an exact science in terms of symptoms or treatment.
That leaves Hollywood filmmakers with a myriad of options for portraying people with diabetes. And high drama reigns.
"There's no law saying we have to be right on in every movie scene," says Donna Cline, who researched diabetes as technical adviser for "Panic Room." "Frankly, we deliver what the public wants. We determine what the public sees, but the public [also] determines what they see by what they pay for. Money really drives a lot of this."
The Ramifications of Wrong
No matter what the root of the story line, dramatic portrayals of people with diabetes are sometimes fraught with inaccuracies or fail to offer a clear picture of the disease and its effects. Many people with diabetes fear that pop culture's take on the disease may help to spread what's already an epidemic of confusion about a condition that affects a growing number of Americans.
"Con Air," for example, contained ghastly inaccuracies and left the audience with the impression that death was imminent for the character with diabetes.
"They had his character behaving more like someone with low blood glucose rather than high [glucose from missing an insulin injection]. He was sweating...and I don't remember any remarks about being thirsty or having to go to the bathroom," notes Laura Feagle of Lynnwood, Washington, who has type 1 diabetes. "His instantaneous recovery once he got his shot was just comical. Uh, no, I don't think so. When I was in DKA...I was in the ICU for several days and feeling rotten pretty much the whole time."
Even when stories involving a person with diabetes are technically accurate, they can lead to misconceptions that linger.
Uninformed women with diabetes still believe they can't have children because of what they saw in "Steel Magnolias."
When "Panic Room" broke box-office records after its spring break release, Donna Gardner was busy writing letters to newspapers. Several film reviewers had incorrectly referred to Sarah's life-saving shot as an "insulin injection."
Gardner was appalled. Her husband, Carey, had been diagnosed with type 1 diabetes nearly two years ago. A friend of his with the same diagnosis almost died after being given insulin by a well-meaning friend during a severe hypoglycemic episode.
"If you have seen the movie, you know Sarah is given glucagon for low blood glucose," she exclaims. "This is outrageous!...A lot of people thought the girl was given insulin in the movie because it was never specifically stated...just that she needed a shot. If you don't know anything about diabetes or glucagon, most people assume that it is insulin."
Dorsey says the issue came up during test screenings.
The key question became, "When do you stop spoon-feeding the audience and experience the movie for what it is?" Dorsey asks. "I think you try to keep the story moving forward while at the same time not harmfully impacting people who have diabetes. I don't know where that falls."
Research Can Make It Right
The "Panic Room" script originally had problems. Cline, the technical adviser, fixed most of them.
"They had things like she was cyanotic, which means she's turning blue, and that's not going to happen with hypoglycemia," Cline recalls. "They had her suddenly and spontaneously recovering. They were going in the right direction, but they were flying about."
It's Cline's job to reel the creative minds behind the movies into reality—at least part of the way. For more than a decade, she has researched subjects—medical issues are a specialty—and helped change scripts and scenes to depict what she learns.
For "Panic Room," Cline researched the appearance and behavior associated with low blood glucose and other aspects of diabetes.
Still, not everything in "Panic Room" was right on.
A few people with diabetes were perplexed by Sarah's ability to wolf down pizza and Coke and end up with low blood glucose.
Others were upset by a comment made by Foster's character: "Sarah, calm down. You know what can happen if you let yourself get worked up."
The comment suggested that her blood glucose would plummet if she got too excited. Not all people with diabetes find this to be true.
When it comes to diabetes, Cline's job isn't easy. How can one possibly decide how to depict a disease that, as the sufferers themselves agree, doesn't affect everyone the same way or involve the same treatment in all cases?
Cline consults textbooks or seeks help from her bulging Rolodex of experts.
She found details about the characteristics leading to hypoglycemia in a manual on cardiopulmonary resuscitation (CPR). One of those characteristics, she says, was "great emotional stress," and this probably was the reason for Foster's line.
Film producer Janet Zucker, whose 14-year-old daughter, Katie, has type 1 diabetes, says research can be tricky.
"You have to do research, but the problem is...if I'm doing a movie about an investment banker, I can go ask three different people about it and get three different answers," cautions Zucker, whose film credits include "Rat Race" and "First Knight." She agrees that "Panic Room" was a little less than technically accurate. "But it definitely got across the urgency of diabetes and how serious it is. I try to look at it in a broader sense."
It All Depends
Cline says her job is all about that broader sense. Her role depends on filmmakers' needs, directors' styles and budgets.
"You have a story to tell," Cline explains. "I always say, 'Let's start out with reality...and then let's cheat responsibly.' Cheating is part of filmmaking because it takes too long otherwise. Filmmaking is broad strokes, and it's up to me to take care of the smaller ones. My job is really to take massive amounts of technical information and edit that research down to visual units that are usable.
"If you come in after they've shot a million-dollar scene and say there's something wrong with it, the response is, 'What do you mean it's inaccurate? We've just spent a million dollars shooting that scene.' We make it work. It's like [the free transform tool] in Adobe PhotoShop...we push and pull a little to make it fit."
Cline also helps movies stretch to new dramatic heights. In "Panic Room," that meant skewing Sarah's blood-glucose readings displayed on her watch slightly lower than they needed to be so that her hypoglycemia was severe enough to warrant a seizure.
"We took some dramatic license to show how serious it was and that she had to get out of that room," says Dorsey, the associate producer. "Saying 'coma' and 'die' may have been overdramatic. Sometimes you have to hit the audience over the head.
"Some [filmmakers] just say, 'Oh, we're going to do this, and it's going to serve the story,' and there's really no concern about reality," Dorsey adds. "Sometimes it gets away from you, and other times you get it about right, and other times you hit it right on the head."
And sometimes filmmakers don't listen, despite Cline's penchant for flexibility.
"I understand that the one thing they do resist is being confined by the black and white that is so often part of technical fields," Cline observes. "They want to get the picture made. They don't want to be bothered with too much. Sometimes they say to me, 'We're making a movie. This is not real.'"
How Much Responsibility?
And so mistakes are made.
Case in point: When asked about a confusing "Panic Room" scene in which Foster orders Sarah to drink lots of water to help keep her blood glucose from falling, Cline only needed to flip through her files to know she had done her job.
"Here it is," she says, before reading from her notes. "'Thirst is not a characteristic of a person having an insulin reaction.' It's right here in my research, and they chose not to change [the scene]."
Those who make movies, live with diabetes or do both agree: Hollywood must take responsibility for accuracy and sensitivity, especially with regard to medical issues.
Cline points out that the public has a responsibility, too.
"I don't think we have to take on the woes of the world and make every picture an advocacy piece with tons of detail," she argues. "It's the public's responsibility, too, to know the context in which they're viewing something. It's wise to not be irresponsible, but being held to every detail down to the last syringe is counter-productive."
Pam Payne of Fairlawn, Ohio, whose 16-year-old daughter, Sara, has had type 1 diabetes since age 8, believes that Hollywood underestimates its influence.
"I couldn't believe the number of people that came out of 'Pearl Harbor' and thought that was the way it happened," she says. "I think the public should have a certain responsibility for being aware of what goes on in our world, but unfortunately I think people look at 'Judge Judy' on TV and think that's what the world is...[Hollywood filmmakers] may not think they are, but they are in the business of educating people. Unfortunately, many people don't go any deeper than going to a movie on a Saturday night, and, to them, that is what is happening in America."
Hollywood Couples Lobby for Research And for Including More People With Diabetes in Movies
Janet Zucker, a film producer and mother of a teenage daughter with diabetes, takes a proactive approach to the issue of diabetes, including its portrayal in the movies.
Along with another Hollywood couple who has a child with diabetes, Zucker and her husband, Jerry, founded CuresNow (Citizens United for Research & Ethics in Science) earlier in 2002 to lobby in favor of embryonic stem cell research. The group sponsors a Web site at www.curesnow.org.
"It's our responsibility to do appropriate research and portray the people as accurately as possible," Zucker notes, speaking from a filmmaker's perspective "But in a dramatic movie, it's not necessarily Hollywood's responsibility to provide education. It's our responsibility to move the story forward and develop the characters of the piece...CuresNow is taking on [educating and promoting research] as a personal responsibility."
Although opposed to human cloning, the nonprofit group believes that stem cells and therapeutic cloning hold the most promise for curing diabetes and many other diseases.
The group has already resurrected advertising characters "Harry" and "Louise," the couple who helped scuttle the Clinton health plan, in commercials taking aim at President George W. Bush's efforts to ban all forms of cloning.
Zucker says that another goal is convincing Hollywood to include more characters with diabetes in story lines, adding that more good than bad will come from the disease being featured on the silver screen, even when it's imperfectly portrayed.
"The more people who are aware of what a dreadful disease it is, the more funding can be gotten and the more people will understand, the more Washington will understand," argues Lucy Fisher, another CuresNow founder and mother of an 11-year-old daughter who has type 1 diabetes. "Most people know what diabetes is but don't know what a horrible disease it is. The best way for that to get across is through an engaging story line."
Just Do It!
Movie Producers 'Swoosh' Watches in 'Panic Room'
By now, many people with diabetes have wondered why the real GlucoWatch Biographer isn't nearly as cute and compact as the watch/monitor they saw in "Panic Room."
That's because it wasn't a GlucoWatch Biographer.
But producers wanted it to be.
Associate producer John Dorsey heard about the product's development in the fall of 2000, when crews were already filming "Panic Room." He thought the item was the perfect candidate for a product placement deal.
Producers approached the manufacturer, Cygnus, Inc., with the idea. But the timing was bad.
The company didn't have a few thousand dollars sitting in an advertising budget yet and was still meandering through the sensitive U.S. Food and Drug Administration (FDA) approval process for the regulated product.
Craig Carlson, chief operating officer for Cygnus, explained that the company decided it was inappropriate to promote a product that wasn't on the market yet and didn't want to jeopardize FDA approval by putting the product in a situation where it could be misrepresented.
"If it were a Coke can, you would not have all those issues," Carlson said.
So what was that cute, compact watch that we saw in "Panic Room"?
"We ended up creating a prototype with a Nike watch," Dorsey said. "It was a little creative stretching, done for the movie."