Health Affairs - Confronting the Growing Issue of Diabetes (Jan 2012 issue) - Warning - LONG RANT

I regularly read Health Affairs for my job, and was excited when I first saw the title on the cover of this month's issue (

And then I started to read the articles...

First, they almost exclusively focus on type 2 diabetes. Thus far (and I'm about halfway through the articles), not a SINGLE ONE is about type 1 diabetes. And, the strong focus of a lot of the articles seems to be about the whole "lifestyle/type 2 diabetes connection" and prevention.

In most of the papers presented, they at least mention that their focus is on type 2 diabetes. ok, that's fine if that's what your research focuses on.

But the worst article I have yet to come across is the one that was also featured today in the NY Times titled, "Diabetes's 'Health Shock' to Schooling and Earnings: Increased Dropout Rates and Lower Wages and Employment In Young Adults." (featured in the NYTimes here).

Now, I'm not here to start any heated debate about which "group" is more deserving of research. I also know that there are many people who fall outside of the traditional "type 1" and "type 2" diabetes categories. I also know that there's a lot we still just don't know about all kinds of diabetes and genetics. Heck, we still don't even know exactly what causes type 1 diabetes!!

But this article takes the cake (pun intended) with this statement: Limitations: As noted above, we were unable to distinguish between type 1 and type 2 diabetes in our data set. However, the abscence of such a distinction should not be considered a major problem. Commonalities between the two types continue to emerge as clinical knowledge of diabetes evolves [citations]. These common features further blur the line between the two, if in fact one exists at all."

What the fructrose?!!??!!?

The article goes to basically conclude that diabetics obtain less education and have lower wages when compared to "non diabetic" peers. To determine if respondents were diabetic, they asked them, "Has a doctor, nurse, or other health care provider ever told you that you have or had high blood sugar or diabetes?"

There are so many problems with this article, I don't even know where to begin. And the more I read it, the more I get angry.

1. Their method for identifying "diabetic" respondents is flawed. I had a friend who, not long ago, was told he had high blood sugar during routine blood work. A second blood test revealed normal blood sugar. Just because you're told once that you have high blood sugar DOES NOT mean you have diabetes.

2. This article constantly uses the term "diabetes" generically, with NO differentiation, and talks about the link between obesity and lifestyle factors with the diagnosis of diabetes.

3. The treatment of T1 versus T2 diabetes is, generally speaking, pretty different. I can think of at least four people in my life who have received a diagnosis of type 2 diabetes (2 friends, 2 coworkers). Two of them control their condition with diet, exercise, and monitoring through their doctor's office, and the other 2 take oral medications. I realize that some T2s do require insulin, but even there there's variation, with some just taking long-acting insulin, and others just taking a mealtime insulin. Type 1s require insulin. Period.

4. Then the authors note that their data do not allow them to probe further into the mechanisms driving their results, but go on to list several potential causes that might explain these relationships. Of course, the first one listed is obesity. Then they talk about the connection between employment and health insurance, but let's face it - when you're a type 1 insulin-dependent diabetic, this relationship is far more serious. We need health insurance to survive in the short-term. It's an immediate life-and-death issue, because if we can't access insulin, we die.

Of course the article also talks about the need for prevention, but last I checked, "prevention" only applies to type 2 diabetes, and even there the evidence is dicey. Aren't something like 1/3 of T2s of normal weight at diagnosis???

Ugh, am I wrong to be so angry about this paper? Health Affairs is a reputable journal within the Health Policy community. In addition, more than ever I'm encountering health professionals who don't even know the basic differences between type 1 and type 2 diabetes. I can't tell you how many times in the last year I've found myself explaining the difference to a nurse or equally well-educated health professional who exclaimed upon me telling them that I had type 1 diabetes, "But you're so thin!" or "So do you manage your diabetes with diet and exercise, or do you take pills too?"

Am I overreacting?

I should also note that I did email the author of another one of the Health Affairs articles (Dr. Kenneth Thorpe) and he at least had the decency to email me back and acknowledge the oversight, and agreed to take it into account in future articles.

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Right, but I don't think this is mandatory until 2014. Also, are such young people covered under this provision required to be unmarried, financially dependent on their parents, or residing at the same address as their parents? I have to go back and look at the legislation, but I think there's gotta be some limiting factors.

Personally, I think for type 1s, the whole insurance necessity is a bigger deal given our very immediate dependence on insulin.

I'll go back and look as well, but I can say that the 26 years of age rule has gone into effect ( it was one of the first parts of the bill enacted).

As for limiting factors, I'll have to check on what they are. I can say that I currently do not live with my parents and work full time and have managed to stay on their plan. I'm sure they exist, I just don't remember what they are.

However, I would definitely agree that health insurance woes are a major issue for type 1 diabetics that don't get the attention they deserve. My co-pay for insulin is 25 bucks, but if I lost insurance, it would take half a paycheck to get it, which is a really scary thought.

Well, that's great if they didn't include any limiting factors or give the states power to do so. At least that. I thing young adults/college-age folks are among the largest group of uninsured people in this country. That's bad enough for healthy young adults who may break a leg or get suddenly sick, but for those of us with a serious chronic condition, it's disastrous.

Yeah, the cost of insulin is definitely frightening. I had to pay out of pocket for a single vial of Humalog not long ago (long story) and it was $170 at the local CVS!!




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