Despite positive trends, diabetes care has a long way to go

The danger of diabetes is not only the immediate risk of very high blood sugar. Diabetes also has many dreaded long-term complications. (In this post I am referring to both type 1 and type 2 diabetes mellitus.) Diabetes greatly increases the risk of stroke, heart attack, and amputation. In the US it is the leading cause of kidney failure and of blindness in adults.

A study performed by researchers at the Centers for Disease Control and Prevention and published in the New England Journal of Medicine tracked the frequency in the US of five serious complications of diabetes over the two decades from 1990 to 2010. This was not an experiment in which a medication or diagnostic test is evaluated. This was simply counting how many people had diabetes in the US, and how many of them suffered heart attacks, strokes, kidney failure, amputations, or death due to very high blood sugar.

The results were very encouraging. The rate of heart attacks among diabetics fell by two thirds, as did the rate of death due to very high blood sugar. This parallels a similar but smaller drop in the frequency of heart attacks in the general population. Stroke and amputation rates both declined by about half. The risk of permanent kidney failure declined by about a quarter.

What accounts for these favorable trends? Part of the credit lies with earlier detection and better treatment of diabetes. Screening for early complications of diabetes by checking for early signs of kidney injury and for the first signs of skin sores helps prevent amputations and kidney failure.

But much of the credit for these positive trends has nothing to do with diabetes, but with general improvements in preventing cardiovascular disease. Fewer people are smoking. Statins have revolutionized treatment for high cholesterol and have drastically reduced the incidence of strokes and heart attacks in the general populations. Improved use of blood pressure medications have also contributed to stroke and heart attack prevention and have prevented kidney failure. And all of these measures have helped reduce the frequency of amputations.

So as cardiovascular risks have declined in the general population, people with diabetes who are at very high risk have benefited most. That’s great news.

The one bit of data in the study that is terrible news is that from 1990 to 2010 the number of people with diabetes in the US grew from 6.5 million to 20.7 million. So the frequency of terrible complications from diabetes is declining, but the number of people subject to these complications has more than tripled. This is terrific news for the individual with diabetes. Diabetes has never been less scary or more manageable. But for the society as a whole, the news is mixed.

To make further progress in decreasing complications from diabetes we must figure out how to stem the tide of the diabetes epidemic. For type 2 diabetes this may mean earlier detection of risk factors and expanded use of weight loss surgery for appropriate patients. It may also mean working to reverse the epidemic of obesity — a quixotic task. For type 1 diabetes this may mean further work on an artificial pancreas and on immunotherapy that might arrest the disease in its very early stages when some pancreatic function remains.

We’ve come a long way. We’ve got a long way to go.

Albert Fuchs is an internal medicine physician who blogs at his self-titled site, Albert Fuchs, MD.

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  • NormRx

    “The one bit of data in the study that is terrible news is that from 1990
    to 2010 the number of people with diabetes in the US grew from 6.5
    million to 20.7″

    In that same 20 year period “normal” blood glucose has also been lowered from 140 to 120, and if you are between 100-120 you are now pre-diabetic. Let’s lower the cutoff to 110 and we can add another 100 million people classified as diabetic.

    The same thing has been done with cholesterol levels and a diagnosis of autism, change the classification and expand the market.

    • Kristy Sokoloski

      Good point about the number classification. I have been worried about this for some time. If they keep lowering the number any further it’s not Diabetes we are going to be worrying about but hypoglycemia.

      • querywoman

        Yup! And shortly before the advent of insulin, one doctor was managing diabetes with 450 calories diets. Of course, they were too weak to stand up.
        The discovery of insulin has been a truly significant medical discovery. Doctors of all nations could describe insulin, the blood sugar, the sweet urine, etc, for centuries before they could treat it.

    • querywoman

      Heh! Heh! And the cutoff used to be 200 in the 1940s to1960s.

  • querywoman

    Probably the biggest key to managing Type II diabetes is getting rid of the blame-the-patient mentality and starting treatment of blood sugar sooner..
    Many people are ashamed to have diabetes and think it is a failure to accept diabetes medicine. Sadly, many doctors fuel this mentality.
    It appears Dr. Fuchs blames body fat for a lot of diabetes. Weight loss surgery is truly risky. It may have some immediate benefits, but long-term complications are well-known.
    Diabetes Type II is a also a degenerative disease associated with aging. Living longer, as in not dying en masse younger from infection disease, couple with the increased lowering of blood sugar standards, has cause the dx of diabetes to blossom.
    New treatments are coming out all the time. I lost 70 pounds from going on Victoza and getting off insulin. I never understood my carbohydrate cravings before, as in why I couldn’t stop eating certain foods.
    Victoza helps me immensely, but it doesn’t work for everyone.

  • querywoman

    Hmmm! Just did some real research on diabetes and history. Since this site doesn’t like hyperlinks, google, “History of Diabetes,” and the, “American Diabetes Association,” for more info.
    Insulin was discovered in 1910. Rememer, folks, there would soon be the Great Flu Epidemic of 1928 that wiped out gobs of humanity, and then two nasty world wars. They didn’t even know flu was a virus. And now many people survive the truly deadly flu/pneumonia combo with antibiotics.
    Up to and through 1924, diabetic mothers lost half of the babies born to them. It took fifty years for one Dr. Priscilla White to raise the birth survival rate to 90%.
    Were these mothers Type I’s? Was their a vague shade between Type I’s and Type II’s? Surely!
    Diabetes is a genetic, hereditary disease. Now assume if Type II diabetes with rising blood sugars develops in the 30s and 40s. Those people will be sensitive to infection and often get sick and die without antibiotics, IV’s, and oxygen, etc. I was sick constantly when my sugars were rising to 325 fasting in my 30s.
    My grandfather was diabetic, probably dx’d with a fasting sugar of 200, not on insulin, and he died in the mid-sixties from a heart attack. His type would live much longer statistically now.
    Insulin and many current medical treatments have enabled many Type II diabetes to live much longer and they have reproduced.
    Now that we have good diabetes treatments, people in modern industrialized countries can get them, but many people won’t comply.
    So we are fatter and live longer, and diabetes treatments are available, but fat is an easy target.
    Keep getting better meds and improve compliance!