Rethinking the "Dark Ages" of Treatment for Type 1 Diabetes

When I was diagnosed with type 1 diabetes as a 7 year-old kid on July 24, 1976, not much had really changed since the discovery of insulin. I began this trip using Clinitest urine testing and that lasted for over a decade. I made slight adjustments to my short-acting insulin if my test results were on the high-end of the scale. Blood glucose monitors were introduced in the mid-1980's, and I recall my family was one of the first to get a meter (since there were two of us who had it, I guess the price was justified); but the other kids I knew used color-coded strips and they told stories of how they could slice the strips in half and double the number of tests they got from a single vial. I remember thinking that was pretty cool.

When I was quite young, I did experience some problems with nocturnal hypoglycemia, and I would wake up in the middle of the night screaming with the most horrible nightmares. I was taken to the hospital as they tried different insulin regimens and finally settled on a combination that worked quite well until the manufacturer stopped making one of the insulin varieties I relied upon for glycemic control. This was my first, rude introduction to the business of diabetes. I struggled to find a comparable insulin with the same kinetics, but I was told, that's the way things were.

Aside from insulin, treatment consisted of adherence to a diet of largely whole foods with strict limits on refined carbohydrates (bread, crackers, rice, potatoes, etc.), and a mandate to ride my bicycle, play ball outside with other kids or do whatever else we could to amuse ourselves (my mother didn't want the kids inside, glued to the TV and pestering her while she prepared dinner anyway). In the summer, we got to spend time swimming in the pool to keep cool. For snacks, we were given things like carrot and celery sticks or peanuts that we shelled ourselves, and we drank water from the hose in the backyard when we were thirsty. Occasionally, we would get unsweetened Kool-Aid that my mother sweetened with Sweet & Low.

For much of my early life, I was treated with that supposedly allergenic animal insulin that I have been told repeatedly by promoters was "unpure" and was supposed to cause all kinds of allergic reactions (although I didn't have any) and I did not have the wild gyrations in my blood glucose levels that kids with diabetes seem to have today. My older sister, who was diagnosed with type 1 in 1969, did have some visible examples of lipodystrophy, but over time, that all but disappeared, probably due to greater purity of the insulin starting in the early 1970's. In fact, I could make a fairly convincing argument that our lifestyle was actually far superior to the way many kids live today.

Interestingly enough, I have actually had parents of newly-diagnosed children make the bold claim that I grew up in the so-called "dark ages" of diabetes care, but I beg to differ with that assessment. Although I can't know for certain because we didn't have an accurate method for monitoring, I believe my blood sugar levels were within a reasonable range. In fact, when I had my first hemoglobin A1C test done (remember, I lived for quite a while before that test was created), my doctor told my parents to keep doing whatever they were doing. Because I have yet to have any real complications so far, I would dare say that I was pretty well cared for in spite of suggestions to the contrary.

In 1982, Eli Lilly and Company received FDA approval for Humulin, which was supposedly human insulin -- just like the body makes (in reality, it is synthetic, a good comparison is the difference between artificial vanilla and natural vanilla -- it tastes similar, but not exactly). I recall that company advertised the heck out of that insulin in magazines like the ADA's Diabetes Forecast and elsewhere, but almost no one I knew with diabetes switched because doctors were reluctant to switch patients who were already doing well with a prescribed treatment plan. Also, the new synthetic human insulin was more expensive and offered no apparent benefit. It wasn't until the company announced plans to discontinue those insulins when patients switched to Humulin en masse.

On the surface, the argument seems logical enough -- that humans should use human insulin, but the reality now looks rather different. First, there is a growing body of evidence that now suggests that human insulin is what the body's immune system is attacking, thus it is one of the causes of type 1 diabetes. In May 2005, for example, the journal Nature published an article which suggested that insulin may itself may be a primary autoantigen for autoimmune diabetes. But the 2005 article was done in mice, and there are sufficient differences between humans and mice to remain skeptical of this finding, even if it was an interesting possibility. But this month, in the January 4, 2008 edition of the journal Current Opinion in Immunology, appears to confirm that finding, and I suspect additional studies will further validate this.

I would add that the SEARCH for Diabetes in Youth, a five-year, $22 million research project that ended in October 2005 jointly funded by the CDC, the NIH/NIDDK and JDRF, found that a growing number of children with a clinical diagnosis of type 2 diabetes also now had signs of autoimmunity. We also know that patients with type 2 who initiate insulin therapy also start to show signs of autoantibodies normally associated with type 1.

Elizabeth Mayer-Davis, Ph.D., the principal investigator for the SEARCH study told JDRF's Countdown in March 2006 "We didn't expect that some 30% of children with a clinical diagnosis of type 2 would have positive diabetes autoantibodies."

With that being the case, we should give serious consideration to the impact that using so-called human insulin (and perhaps moreso with non-insulin products like insulin analogs) have on the population this medicine is supposed to be helping.

In retrospect, I'm not convinced that I lived in the "dark ages" of diabetes treatment and witnessed a great awakening while I was growing up. In fact, I would argue quite the opposite. Sound dietary and exercise habits, combined with highly purified animal insulin was far better than today's kids have it.