Related Documents
Declining Death Rates From Hyperglycemic Crisis Among Adults With Diabetes, U.S., 1985-2002 (Diabetes Care, Volume 29, Number 9, September 2006)
Before there was insulin diabetes was fatal, usually in a few weeks, always in a year. Even today some people die from type 1 diabetes. Our concern in this era of diabetes management is using all of the tools we have to simulate the activity of islets of Langerhans; the input is insulin and the output is glucose levels in the blood. The goal of the therapy system is constant blood sugar near the normal of 5mM (80 mg/dL). Frequent blood sugar measurements, calorie counting and the multitude of insulins (or the pump) can be used with diligence for reasonable control. So the effects we seek to avoid are long-term and vascular: kidney failure, retina damage, etc.
This was not so a hundred years ago. Diabetes was a death sentence and the executioner was hyperglycemic crisis. Without insulin to inject blood sugar goes higher and higher limited only by the amount dumped into the urine by the stressed kidneys. Hence the classic triad of untreated type 1 diabetes: polyuria, polydypsia, polyphagia. Polyuria — huge urine production — helps the body dispose of the extra glucose. Polydypsia — drinking a lot of water — replaces the water lost in urine. And polyphagia — eating — replaces the calories lost in the sugary urine.
One of the posters that caught my eye at the June meeting of the American Diabetes Association concerned the death rate — today — from hyperglycemic crises. The authors analyzed death records and determined that fatalities caused by untreated diabetes were declining. The graph shows the death rate for three age groups.
They estimate that in the United States about 2,500 people died of untreated diabetes in 2002. The rate is declining, especially among the elderly. (The authors did not include children because they consider the statistics unreliable. Based on the numbers I know, the number of children dying from untreated diabetes is probably around 200 to 400 per year).
Since the only data in the study was reported cause of death, the reasons for the decline could not be determined.
It is sobering to think that a few thousand people die from lack of insulin every year in the United States, insulin found in every emergency room.
But is is encouraging to note that the death from lack of insulin treatment of diabetes has gone from 100% to 0.02% in the century since insulin was made available.Before there was insulin diabetes was fatal, usually in a few weeks, always in a year. Even today some people die from type 1 diabetes.
At the opposite end of the spectrum, under the new strict blood sugar control protocols there has been a tripling of episodes of severe hypoglycemia. (V. Briscoe, et al, “Hypoglycemia in Type 1 and Type 2 Diabetes,” Clinical Diabetes, vol. 24, no. 3, p. 115 (2096)) Since 55% of severe hypoglycemia episodes occur during sleep, the patients are often defenseless against them. (“Epidemiology of Severe Hypoglycemia in the DCCT,” American Journal of Medicine, vol. 92, no. 3, p. 339 (1992)) Nocturnal hypoglycemia is thought to account for the ‘dead-in-bed’ syndrome in type 1 diabetics, and accounts for 6% of deaths in type 1 diabetics under age 40. (L. Perlmutter, et al, “Glycemic Control and Hypoglycemia,” Diabetes Care, vol. 31, p. 2072 (2008)) The NIH reports that 2% to 4% of type 1 diabetics die from hypoglycemia, which causes 48,000 hospitalizations in the U.S. each year. Those patients who survive episodes of severe hypoglycemia and the many accidents associated with them face a high likelihood of suffering permanent brain damage from the interruption to normal brain metabolic processes. (M. Fugioka, et al, “Specific Changes in the Human Brain after Hypoglycemic Injury,” Stroke, vol. 28, p. 584 (1997))
With all this morbidity and mortality from strict blood sugar control, eventually the rising curve of hypoglycemic death in diabetics may meet and cross the sinking curve of hyperglycemic death in diabetes, making intensive control truly ‘a cure worse than the disease.’
You are absolutely right — tight control leads to greater hypoglycemia, but the hypoglycimic episodes are much less severe. Reportedly hospitalization required is much less.
Your point that death by hypoglycemia is now more important that death by hyperglycemia is certainly true. 2% death from hypoglycemia and complications is much higher 0.02% from hyperglycemia.