knowledge is power:

Diabetes 101

A Disease of Massive Proportions.

There are presently approximately 30 million diabetics in the U.S. and about 400 million worldwide, some 90+% of which are Type 2 who develop insulin resistance over time, as opposed to Type 1 diabetics whose bodies do not produce insulin at all.  This is, by population, the most common disease in the world.

Various estimates put the growth rate of the disease at between 10%-15% annually.  What is clear is that many experts have vastly underestimated the scope of this pandemic.  It seems to be accelerating.  For example, according to a 2001 study in the American Diabetes Association magazine, Diabetes Care, “The number of Americans with diagnosed diabetes is projected to increase 165%, from 11 million in 2000 to 29 million in 2050.”  America passed the projection for 2050 by 2015, 35 five years SOONER than expected.  This same phenomenon has occurred in other parts of the world.

All told diabetes affects over 1 billion people around the globe.  According to Alfred Mann, a pioneer in the field, "diabetes is not the greatest healthcare challenge facing the world.  It is the greatest challenge facing the world".

Poor Control.

Diabetes is a chronic, incurable condition that worsens with time.  Without medication it is fatal.

The recognized, standard measurement of the control of one’s diabetes is something called HbA1c.  The lower HbA1c, the better.  Normal, non-diabetic patients have levels below 5.7.  At a level above 6 a person is considered diabetic.  Presently, the very best managed diabetic patients have levels at about 6.5.  Most diabetics are above 7.  Also, HbA1c levels get worse with time.  It’s a little like vision in the sense that once a person begins correcting vision, every couple years that person needs a stronger correction.  A diabetic with an HbA1c of 6.5 will, in time, have much higher numbers.

To put these HbA1c numbers in perspective, one needs to understand how they correlate to blood glucose levels.  See Table 1 below.  Generally an HbA1c reading of 5 corresponds to an average blood glucose level of about 100.  You can see the corresponding blood glucose values as HbA1c rises.   Importantly, blood glucose levels are what drive the problems that bedevil diabetics.  Elevated glucose levels maintained for a number of years will result in severe problems.  Microvascular damage begins to occur at blood glucose levels of 140 and above.  Long term microvascular damage is what causes the problems associated with diabetes like heart disease, stroke, blindness, kidney failure, amputations, peripheral neuropathy etc.  All worsen as blood glucose rises.  A blood glucose level of 140 corresponds to an HbA1c of approximately 6.5.  Yet, as previously stated, most patients are well above this level.

More troubling, the American Diabetes Association generally guides physicians to manage their diabetic patients to an HbA1c between 6.5 and 7.  Why would the experts in the field recommend blood glucose levels in a range that virtually guarantees long term damage? The answer is... hypoglycemia.

Table 1
HbA1c (%) eAG (mg/dL) eAG (mmol/l)
5 97 5.4
6 126 7.0
7 154 8.6
8 183 10.2
9 212 11.8
10 240 13.4
11 269 14.9
12 298 16.5


Hypoglycemia is the condition of low blood glucose.  At the extremes, hypoglycemia can cause brain damage, coma or death.

Further, hypoglycemia often occurs at night when a diabetic is asleep so the onset can be unnoticed until it is too late.  Blood glucose levels fluctuate wildly throughout the day.  To keep the blood glucose level from going too low, the experts recommend keeping the average level at a higher than optimal point.  In other words, to reduce the possibility of death from hypoglycemia in the short term, the experts recommend average glucose levels that are likely to lead to death in the long term.

The average type 1 diabetic dies about 10 years sooner than normal, and the average type 2 dies 6 -10 years earlier than normal.  Higher HbA1c means a shorter life.

The Goldilocks Problem – Too High, Too Low.

So, as you see from the discussion surrounding Table 1 above, blood glucose levels that are too high can lead to very serious long-term complications, but glucose levels that are too low can result in very severe short-term complications.  And, compounding this problem is the fact that the patient cannot see his/her blood glucose levels.  It’s not until blood glucose levels get extreme in either direction that some patients can begin to notice.  By this point, however, it could be too late.  This is the key to understanding the difficulty in treating this disease.