This article in yesterday's edition of Endocrine Today makes me scratch my head. First and foremost, had this study been conducted in 1976 in the US and not in Germany, I would have been included in these statistics. Given that, why did they spend money on this? What do they hope to attain by learning that ketoacidosis in juvenile onset diabetes is frequent? Do they think somehow they can prevent the phenomenon?
I don't think a high incidence of ketoacidosis in true juvenile onset type 1 diabetes diagnosis is particularly preventable. Why? Let's start with the fact that the progression of the disease normally goes from 0 to 100 mph very rapidly. Then continue with the fact that kids normally only go to the doctor for a routine annual physical at most annually. Then there's the fact that glucose and c-peptide tests are not part of a physical.
I would expect that glucose testing due to the high incidence of type 2 might be added sooner or later but the real indicator of juvenile onset type 1 is in insulin production and beta cell destruction which would more likely be seen in a c-peptide test. When does beta cell destruction start in earnest? Is it consistent?
There's no way anyone is going to mandate a c-peptide test at a routine annual physical AND force insurers to pay for it primarily because the incidence of true juvenile onset type 1 diabetes is so low relative to the total population. They are truly more concerned with the incidence of type 2 in the total population. No big surprise - higher incidence means higher cost means more interest in preventing problems.
Why do I think that a standard A1C, random glucose or glucose tolerance won't catch juvenile onset type 1 before ketoacidosis? Because unless someone gets real lucky it happens too quickly for a routine annual physical to catch. And unlessl you've got a PCP who is really on his/her toes the early symptoms are pretty darn subtle. That's if you go to one 'just cause.
I remember being particularly thirsty for about 3 months prior to my diagnosis. But it was hot and I was 12 and spent a lot of time outside. I was active. So, thirst by itself just wasn't going to stand out by itself.
Then there was the hungry horror stage which quickly ran into the weight loss stage (10 pound loss of a 72 pound child in one week) which only started one week before diagnosis. The final stage was what we know as the ketoacidosis stage which to the normal average bear initially resembles a flu. And who on earth takes their kid to the doctor immediately upon flu symptoms? Who can get an appointment immediately at flu symptoms? Two days later ... ya, well that's what got everyone's attention.
The stench of ketoacidosis, the lethargy and being totally out of it stage. That was it. Apparently, I couldn't even walk because I remember my mom carrying me to the car.
But I had only missed one day of school at that point. It really is fast. My birthday was Thursday. I went to school on Friday. We moved on Saturday. I went to a Halloween party on Sunday. I was notably drinking soda I didn't drink and eating much more than normal. But again, we had moved on Saturday and I wasn't the type to wait around for someone to unpack my belongings so I was active - translation - hungry. Who knew?
Monday was All Saint's Day and we had the day off. I was sick. My sister was getting me tea. But again, only it was only day 1 of being sick so who would take the kid to the doctor's. I'm a kid; I get sick.
Tuesday was the difference. My sister went to school; Mom went to work and she did not like what she saw when she got home so off to South Shore Hospital she carried me. Thanks Mom. Thanks South Shore Hospital. Thanks Banting and Best. I felt better in short order. I remember being quite perky on the trip to the Deaconess/Joslin.
I do not think my diagnosis could have happened much more quickly. The early symptoms resemble nothing important, nothing notable. I had seen commercials pointing out the symptoms and had mentioned them but to repeat - being thirsty during the summer and being hungry when running around is just not remarkable to the average bear.
So do we demand that extensive tests be run on kids at routine annual physicals just in case? Urine testing as they do in parts of Tokyo (mostly catching type 2)? Do we demand A1Cs every three months which MIGHT pick something up? Will more education of symptoms to parents and PCPS/pediatricians help?
See I don't think so. Paranoia is expensive and not all the helpful considering the relatively low number of juvenile onset type 1 diagnoses per year. (I'm having trouble finding a total number of juvenile onset type 1 diagnosis.) A 1999 study employing genetic testing and CONTINUOUS beta cell damage testing results in "less severe disease presentation." Not the word "continous." There is certainly nothing cheap about genetic testing and there is nothing cheap about continuously looking for autoimmune destruction of beta cells thus rendering the concept unrealistic.
I just don't think there is a simple, cost effective answer to preventing ketoacidosis. I'm sure parents will disagree with me. I hear screaming from the rooftops. However, if this were your business and you had to determine cost benefit, what would it show? Not much benefit. The benefit is emotional and, right or wrong, that just doesn't (usually) count in business decisions. So, in this world of capitalistic, shareholder or taxpayer owned insurance companies, it's not likely to count here either. Sorry.
Doris J. Dickson