So Doc, Am I Going to Die From My Diabetes?
“So doc, am I going to die from my diabetes, and what complication will I get first?” This is exactly what a young man with diabetes asked me the other day. His name is Steven, he is 48 years old, and was diagnosed with type 1 diabetes at age 13 years. He was my patient from diagnosis until 1983, when he was enrolled in the Diabetes Control and Complications Trial (DCCT). At that point, he became not only my patient, but also a research study volunteer in a study that our medical school and 20 others across North America (19 centers in the U.S., and 2 in Canada) were conducting. Steven graduated from college, and went on to get an advanced degree. Along the way, he got married and has two children. When the DCCT ended in 1993, he had to find a physician for his routine diabetes care, but I have continued to follow him as a research study volunteer in the Epidemiology of Diabetes Interventions and Complications (EDIC), the ongoing follow-up study of the DCCT research volunteers. So, I have been able to track his diabetes continuously for about 33 years.
Cliff Notes About the DCCT/EDIC
I assume that most of you already know quite a bit about the DCCT and the EDIC (now called the DCCT/EDIC). But, just to be sure that no one who reads this entry, is in the dark about those studies, I will briefly summarize them (I have probably written quite a bit about the DCCT/EDIC in earlier entries- feel free to check them out of you wish). The DCCT/EDIC is a National Institutes of Health (NIH)- sponsored research project that began in 1982. The purpose of the DCCT/EDIC was to determine if blood glucose control had any bearing on a diabetic person’s risk of developing complications of the disease, such as eye, kidney, nerve, and cardiovascular diseases. This question had been fiercely debated by the experts for quite a number of years. The DCCT/EDIC offered the best hope of resolving this important debate, and only because new diabetes treatment tools had been developed in the 1970; for example, fingerstick blood glucose testing, intensive insulin treatment regimens, including use of insulin infusion pumps, and hemoglobin A1c (HbA1c), a new blood test that could quantify a person’s average blood glucose level over the previous 3-4 months. To make a long story short, the DCCT recruited 1441 people with type 1 diabetes (ages 13-39 years) who were followed for almost 10 years, with study results announced in June of 1993. What did the study show? Only that there was an incontrovertible direct relationship between blood glucose control and the risk of developing diabetes chronic complications. When the DCCT ended, it was replaced by the EDIC, a study of the original DCCT research volunteers, but with less frequent follow-up; once-a-year visits rather than up to once-a-month visits.
So a few days ago, Steven came to see me for his annual DCCT/EDIC follow-up visit, and that was when he asked me the question I quoted above. I do not recall that anyone had ever asked me that question, at least in such a point blank manner. Before I tell you what I told him, let me tell you a bit more about Steven. From the beginning, he has been what I would call a model patient and study volunteer. He took good care of his diabetes, even as a busy teen-ager. His general health has been excellent. He is being treated with a multiple daily insulin injection regimen (4 injections per day). He has never been much interested in getting an insulin pump. Besides insulin, his medications include a baby aspirin, a multivitamin, a “statin”, and an “ACE” inhibitor. His weight is normal, he exercise regularly, and his blood pressure has been normal. With respect to laboratory studies, his blood lipid profile is normal, and his HbA1c has averaged about 6.5% over the past 33 years (his HbA1c the other day was 6.5%). He has had occasional hypoglycemic episodes, mostly with exercise, but none that he could not treat himself. He tests fingerstick blood glucose levels 4-6 times daily. With respect to diabetes complications, he has had occasional microaneurysms (ballooning of retinal capillaries) detected during eye examinations, but no other problems.
What Did I Tell Him?
First I told him that I did not have a crystal ball, but that based on results from research studies, primarily the DCCT/EDIC, it was highly unlikely that he would develop any clinically significant diabetes complications, and if he did develop any, assuming he continues to take care of himself, it would be many. many years down the road. I pointed out that the most recent studies show that the life expectancy for people with well-controlled type 1 diabetes is now about the same as for people who do not have diabetes. If you think about it, that is a rather incredible statistic- in 1965 when I first started seeing children with diabetes, their life expectancy was about 25 years from the time of the diabetes diagnosis! I did remind Steven that type 1 diabetes is generally an auto-immune disorder, and that he and his doctor should be on the look-out for associated auto-immune disorders such as thyroiditis, pernicious anemia (vitamin B12 deficiency), and celiac disease (sensitivity to gluten). I emphasized that Steven’s greatest health risk from the diabetes was hypoglycemia, and that he should never forget to monitor his blood glucose levels, particularly before driving. With respect to diabetes, I am certainly glad it is 2015 and not 1965. Without a doubt, we still have a long way to go in improving the care of people with type 1 diabetes. Doing well with diabetes is very demanding, and some people are just not up to the challenge. A cure would be nice. But until that happens, our patients need to continuously strive to do as well as possible with their diabetes care. The pay-off is huge. I may not have a crystal ball, but I have the next best thing- good data.