Since the advent of insulin in the 1920s, deaths from type 1 diabetes have steadily decreased. In the decades since, innovations and technologies have prolonged patients’ lives even longer, and with far fewer complications from the disease.
But that doesn’t mean our work is done. Joslin physicians Lori Laffel, M.D., M.P.H., Chief of Clinical Programs for Children, Adolescents and Young Adults at Joslin Diabetes Center, Senior Investigator in the Section on Genetics and Epidemiology and Professor of Pediatrics at Harvard Medical School, and Michelle Katz, M.D., M.P.H., Associate Director of the Pediatric, Adolescent and Young Adult Section at Joslin Diabetes Center and Instructor of Medicine at Harvard Medical School, recently co-authored an editorial in the January issue of the Journal of the American Medical Association. In response to two studies also published in the January issue, Drs. Laffel and Katz aimed to comment on the current trends of type 1 mortality, its historical context, and what still needs to be done to prolong the lives of type 1 patients.
To fully realize the potential benefits for persons with type 1 diabetes from the information presented in these papers, Dr. Katz and Dr. Laffel focus on recommendations for achieving life-long glycemic control. Their editorial identifies special areas of concern, particularly during the transition from pediatric care into adult care, and suggests outreach efforts to make sure these patients don’t fall too far behind in their self-care
“These papers are very important and we were pleased to write an editorial framing the studies within the context of management of type 1 diabetes in the 21st century, both locally and globally,” says Dr. Laffel.
The first paper was a follow up study to the landmark Diabetes Control and Complications Trial (DCCT). Participants in the intervention group of this trial, which began about 30 years ago, underwent a period of intensive insulin therapy for seven years. The DCCT established intensive insulin therapy as the standard of care in type 1 diabetes. “This recent paper followed-up on DCCT patients about 27 years later,” says Dr. Laffel. “The authors found that the intervention group had a significantly better survival rate than the group that was randomized to conventional therapy.”
The second paper was a Scottish study comparing lifespans of those with type 1 diabetes to the average Scottish population. The study demonstrated that there is still a gap in survival for those with type 1 diabetes compared to those without type 1 diabetes. “There’s roughly a decade of life that appears to be lost with type 1 diabetes according to the Scottish study,” says Dr. Laffel. (This study, however, was done on a small sample size and may not be representative of other populations.)
Dr. Katz thinks it’s important to view these two new studies within a broader medical context. “There’s been tremendous improvement in mortality over time,” says Dr. Katz. “Both the advent of insulin and the use of intensive insulin therapy, as we’re learning from the DCCT, have both impacted mortality,” says Dr. Katz.
Before insulin was introduced, there were more deaths associated with acute complications, specifically diabetic ketoacidosis. Now, patients with type 1 diabetes are living longer, healthier lives and passing away from chronic diabetes complications such as kidney failure and heart disease at much older ages.
New research, particularly from the follow-up study of the DCCT, suggests that early interventions have positive repercussions later in life. “Twenty seven years later, this period of intensive control still impacted mortality and was able to benefit people,” says Dr. Katz. “Even though in the intervening period the two groups were really similar,” with respect to glycemic control.
During childhood, many type 1 patients are highly regulated by their parents and care providers. But around the time when teenagers are going to college and living on their own for the first time, they’re also shifting to less intensive management of their diabetes. This period potentially sets the stage for the rest of a patient’s life, and if newly independent patients are non-adherent, have poor glycemic control, and increased occurrence of acute diabetes complications, they can be increasing their mortality risk later in life.
“Diabetes health care teams need to provide outreach and support for individuals with type 1 diabetes who may be struggling,” says Dr. Laffel, “both early on and throughout the patients’ lives.”
From the data presented in these articles, Dr. Katz and Dr. Laffel recognize that deaths occurring under the age of 50 are mainly the result of acute complications, like diabetic ketoacidosis or severe hypoglycemia, which are potentially preventable. These younger patients are likely juggling the many demands of type 1 diabetes as well as the demands of adulthood.
“We need to reach out to individuals who might not be getting all the appropriate care and support that they need,” says Dr. Laffel. “And that’s really hard and it’s an area where we need to be creative.”
What Drs. Laffel and Katz are hoping for is more time and better reimbursement for diabetes care teams to work with patients with type 1 diabetes and their families to tackle the challenges of achieving target glycemic control. “It’s not easy to get blood sugars down to target levels,” says Dr. Katz. “Modern technologies like insulin pumps and CGMs have been really helpful, but at this point, they have not decreased diabetes burden.” Additionally, they require substantial time and effort to implement.
Dr. Laffel comments that physicians and diabetes health care teams have to find ways to translate the DCCT interventions into routine care. “How do we optimize glycemic control so that A1C levels are around 7 percent for all patients with diabetes, like those intensively treated during the DCCT? That’s what we have to tackle next,” says Dr. Laffel.
It takes the attention of patients, the support of their families, as well as their team of diabetes care providers. Physicians and educators need to work with type 1 patients, supporting them, and troubleshooting with them to try and make diabetes fit within their lifestyles. And in turn, insurance companies need to offer better models for reimbursement to support these intensive interventions. When it comes to increasing life expectancy for type 1 diabetes, the burden must be shouldered by everyone. “I think that’s the here and now challenge,” says Dr. Laffel.