Perspective/Type 1 Diabetes
November 14 is World Diabetes Day, the birthday of the man who co-discovered insulin in 1921. Frederick Banting and several colleagues developed ways to purify and produce it, and were awarded patents, which they sold to the University of Toronto for $1 each. Type 1 diabetes (T1) would no longer be a death sentence. Banting famously declared, “Insulin does not belong to me, it belongs to the world.”
Yet 100 years later, much of the world’s population still lacks reliable access, if any, to insulin, refrigeration to store it, hand-held glucometers to self-monitor blood glucose (BG), health staff trained to diagnose and treat diabetes, and instruction in self-managing it. The World Health Organization’s (WHO) theme for Diabetes Day in 2021-2023 is Access to Care, with 2022 focusing on Access to Diabetes Education. Obtaining essential diabetes supplies means little if people aren’t taught how to use them safely and effectively.
The WHO and the International Diabetes Federation (IDF) established Diabetes Day in 1991 to draw attention to the threats that increasing rates of diabetes pose to health and economic development worldwide. The JDF Diabetes Atlas 2021 reports that one in ten adults aged 20-79 (537 million) are living with diabetes, 44% of them undiagnosed. By 2045, it projected one in eight adults worldwide (764 million) will have diabetes. The aging of national populations is also fueling the epidemic. According to a 2021 CDC report, nearly one in four Americans ages 65 or older has diabetes, and another two in four have prediabetes.
The national and personal burdens of diabetes are heavy. WHO’s online data show that both the global incidence (new cases) and prevalence (all cases) of diabetes in 2019 were over twice that of other chronic diseases, including heart disease, stroke, chronic obstructive pulmonary disease (COPD), and lung cancer. A 2020 Lancet analysis of 2019 WHO data found that people tend to live more years with diabetes than people do with these other chronic diseases, but that it disables them for twice as many years.
The American Diabetes Association (ADA) estimated that people with diagnosed diabetes in the U.S. had medical expenditures 2.3 times greater (by $9,601) in 2017 than they would have incurred without diabetes. The ADA estimated the total cost of diagnosed diabetes at $327 billion that year: $237 billion in direct medical costs and $90 billion in reduced productivity.
Diabetes accounted for one in four dollars the U.S. spent on health care that year. Costs are rising in all regions of the world, especially as the prevalence of diabetes in low- and middle-income countries rises to meet that in high-income countries.
Rates of T1 have risen somewhat in recent years, but rates of type 2 (T2) have ballooned worldwide. T2 accounts for 90-95 percent of cases; T1 for about five percent. Both can be treated but neither cured. T1 is an unpreventable autoimmune disorder. T2 is mostly preventable because its key risk factors are modifiable: obesity, sedentary lifestyle, smoking and alcohol misuse. Both types lead to high levels of glucose in the blood, although for different reasons. In T1, the pancreas stops producing enough insulin to move blood glucose (BG) into the body’s energy-hungry cells. In T2, the pancreas produces sufficient insulin, but the cells resist accepting its deliveries of glucose. Persistently too-high BG levels (hyperglycemia) gradually damages multiple organ systems, eventuating in complications such as cardiovascular disease, kidney disease, peripheral neuropathy, blindness and limb amputation.
Healthcare professionals formulate diabetes treatment regimens, but patients must implement them to keep BG within a healthy range. Eating a healthy diet, maintaining normal weight, being physically active, taking medications as directed, monitoring BG, correcting out-of-range BGs by adjusting medication, diet and activity level as needed, and following sick-day rules are all crucial. Continual vigilance and problem solving, modifying lifestyle and routines, and adapting to disease progression are inherent to controlling BG. A 2008 ADA survey of diabetes educators concluded that diabetes self-management for adults takes four hours/day, while caring for a T1 child takes five hours/day. Shockingly, the same study found that fewer than seven percent of diabetes patients received diabetes self-management education and support (DSMES) in their first year after diagnosis.
Keeping BG in range is especially difficult and hazardous with T1. Survival requires insulin, but it must be dosed carefully to avoid a sudden, steep drop in BG (called an insulin reaction).
Overestimating carbohydrate intake (and thus insulin required) or injecting more insulin than intended can plunge BG so low that it starves the brain of glucose and risks coma, even death, if not reversed quickly. A 2014 study in the Journal of the American Medical Association reported that, in the U.S., a third of all people with diagnosed diabetes (not just the five percent with T1) were using insulin, and that there are nearly 100,000 emergency visits and 30,000 hospitalizations annually for insulin-related hypoglycemia and errors (IHEs).
Clinical Endocrinology News recently reported a survey in which diabetes patients rated diabetes education, delivered by professional diabetes educators, as the biggest advancement they had experienced in diabetes care. Without it, patients have difficulty taking advantage of essential diabetes technologies and seeing why they should try. Nor will they understand why and how to change habits that lead to life-threatening complications. Lack of education and training for such a complex, draining job guarantees high rates of patient error, distress, non-adherence to treatment and complications.
World Diabetes Day is much more than a yearly one-day campaign, but a call for global collaborations to control the diabetes epidemic and to “keep the 100-year-old promise” of worldwide access to the essentials in diabetes care, including instruction on how to use diabetes supplies safely and effectively.
Lisa Seitles and her husband Sam are the owners of READ Preschool and Camp Tuscaloosa. They have four children and are active members of the community.