The cost of diabetes | Hacker News Reader

The cost of diabetes

diabetes.org

30 pointsdjoldman21 comments

It is a horrible disease - my sister was born with Type 1, and was lucky enough to be offered a pancreas transplantation some 10 years ago. Unfortunately her body rejected it after a year or two, and she was on immune depressants ever since, while waiting for a new one.

She works in fitness, and lives a very active and healthy lifestyle - but still the diabetes was progressing, slowly but surely. Those new automatic pumps turned out to be a lifesaver, and she opted to get off the immune depressants due to likelihood of other nasty stuff that those bring (cancers, infections, decreased fertility, etc.). Hopefully these pumps will work so precisely, that the damage from inconsistent insulin levels will be a thing of the past.

But she obviously still needs insulin. Luckily we live in a country where that is more or less free, and always in stock. I honestly can't remember the last time she suffered from bouts of low blood sugar - which was unfortunately a very regular thing back when we were teens.

Unfortunately that was not the case for my old HS gym teacher. He, too, led a very active and healthy lifestyle, but the disease progressed in a very insidious way for him. He developed a foot sore that wouldn't heal, and after some time they decided to amputate said foot from ankle.

Then he had a heart-attack some months later, and was bound to the wheelchair. Which was followed by two more amputations, the other leg and one arm. He lived like that for some years before ending up blind, and doing longer stays at the hospital. Finally a massive stroke got him, and that was it.

I think he spent some like 5 years from amputating the first leg, to passing away. And as you can guess, that included tons of hospital visits / stays, medication, physical therapy, becoming dependent on your friends and family, and what not.

It is truly insidious, because it can completely wreck your body in so many ways, and pretty slowly too. I can't imagine having diabetes w/complications, and living underinsured (or without insurance) in a country without universal healthcare. It seems like to have a fighting chance, you need consistent insulin supply, and modern delivery systems.

I shudder when I hear about poor people in the US rationing insulin, and still being dependent on those antiquated measurement/delivery devices. Seems like you're just entering a negative feedback loop, which will eventually catch up with you.

> and modern delivery systems.

While I'd agree with most of what you say, I disagree with this. Using a syringe and manually taking insulin is perfectly workable. Personally, I have chosen to go with manual insulin injections over a pump.

That being said, the invention of the CGM (continuous glucose monitor) is, in my opinion, the single best thing to happen for diabetics since the advent of synthetic insulin. Being able to know what your blood sugar is with no effort at all, and being alerted when it's high or low... is just life changing.

I can understand your perspective since I've lived with Type 1 diabetes for most of my life.

However, CGM is a technology which may have serious, life-threatening side effects when its data is inaccurate and used in concert with a hybrid closed loop insulin pump. In patients like me, the frequency of bad data is daily.

"Being able to know what your blood sugar is with no effort at all, and being alerted when it's high or low... is just life changing".

That may be true as long as we include death and serious injury as the "life changing" events that they are.

CGM is useful technology but "life changing" is assuming a level of execution that does not exist in the current generations of CGM technology that I've used, which include Dexcom G6 and Freestyle Libre 2.

It is well understood in the research community of MD-PhD's that interstitial fluid in adipose tissue is a reasonable proxy for plasma blood glucose with the correct algorithmic approach, but it is not perfect.

Particularly in patients who have low adipose tissue, the data emitted from these sensor devices is frequently wrong at fasting times such as exercise and sleep.

I've worn an insulin pump for more than twenty years and used Medtronic, Dexcom, and Abbott for their CGM data in recent years.

The sensors have been replaced under warranty dozens of times, due to inaccurate readings, the last of which I submitted today, when the pump alarmed at 1:30 AM last night reporting that my CGM BG was 50, when my plasma BG reading was 112, the former of which is hypoglycemic while the latter of which is slightly hyperglycemic. I've seen much larger variations than that.

We'll leave the fact that my quality of sleep has been destroyed by these devices for another discussion. This is frequently nightly.

The problem is this: at night or during exercise, when fasting states are both reasonable and customary since it's difficult to eat and sleep or eat and exercise concurrently, innacurate CGM data can induce the pump to either increase insulin delivery, decrease insulin delivery, or stop delivery entirely.

In turn, those 3 conditions can result in hypoglycemia or hyperglycemia, either of which can result in injury or death.

So while diabetes is a difficult disease, it must be noted that exogenous insulin is like any other prescription medication - there are side effects.

Further, technological solutions such as hybrid closed loop insulin pump systems, when used in concert with CGM, may have deadly side effects that are not clearly communicated, nor are they pursued with vigor in the billion dollar companies who promote these products.

Given what I've seen, I've merely warned my doctor and the FDA of the need for oversight and regulation in these markets.

I'm hopeful that the products do eventually get fixed, but having worked in medical devices, I'm not optimistic given the history of the FDA's involvement in insulin pump security breaches in the last decade.

While I agree that CGMs may not be perfect, and they are worse for some people than for others, I still stand firm on the opinion that they are life changing.

- My understanding of how my blood reacts to various foods has increase by orders of magnitude

- My level of comfort with my blood sugar getting too low, especially when I'm sleeping, has vastly increase

- The number of times I've gone into a low blood sugar reaction and had to have an ambulance called has dropped from once a year (sometimes more) to never.

Sure, it's wrong sometimes. I don't use a pump. I do manually test my blood sugar (finger prick) wheneven it feels "off" compared to what the CGM says. But overall, my life is so much better with the CGM than before it that I just can't say enough good things.

I agree that they’re quite imperfect. However, as people with Type 1 we don’t have the option of perfect. The alternative to CGMs is finger- pricking. The alternative to pumps is long-acting insulin.

A semi-closed loop pump will give you a basal rate that changes through the day, informed by the CGM. A long-acting insulin dose (eg, Lantus) will give you a basal rate that changes through the day, due to absorption rate, temperature, exercise, etc.

Now, neither Basal rate will match your bodies needs minute-by-minute. But even with the CGM & looped pump regularly getting it wrong (which it does), it’s still I think getting it much less wrong than inject-and-pray long-acting insulin treatment.

As for risks, I had to do two days of training to get my pump and another online course to turn in the hybrid-closed-loop. That’s more than when I was given a glucometer and insulin pen when I was diagnosed, and it’s pretty easy to kill yourself with those.

I don't think you're understanding the problem.

Two days of training is incredibly short given the complexity.

Killing yourself at your own hand is well-understood culturally, clinically, and legally. The mechanisms of insulin-induced trauma have been well understood since insulin shock therapy:

https://en.wikipedia.org/wiki/Insulin_shock_therapy

and Klaus von Bulow:

https://en.wikipedia.org/wiki/Sunny_von_B%C3%BClow

Being killed by a machine, on the other hand, directly or indirectly may be understood culturally from the long list of science fiction films featuring killer robots, but less so clinically and legally, because we don't have agreement or consensus on accidental death and the role of technology in rising risks in a complex systems environment.

We need to take the implications of the design of medical device autonomy seriously as we approach these problems with those solutions, since they often fail a definition of complete autonomy, but may in fact be considered close enough to pass the same standard of risk and care as we'd give to autonomous robots in industrial settings or self-driving cars.

Just because the administration of drugs doesn't seem particularly robotic, when that administration is beyond a certain percentage of machine control, I'd argue that it is behaving autonomously even though the control mechanisms fall short of machine learning.

It's as if we took Therac 25 and strapped it to a patient's belt with the oncology planning encoded in the radiation device. It may seem as if the complexity is less, but we don't have consensus on that either:

https://www.scielo.br/j/rbepid/a/Mn7DTtCYQLL5gkJgBb8XP3q/?la...

https://en.wikipedia.org/wiki/Therac-25

You can reverse type 2 diabetes. Doctors in Australia, the UK and the US have done that for decades by recommending low carb diets.

most type 2 diabetics can eliminate high blood sugar by simply eating less than 50 grams per day of carbs and exercising every day....do that and blood sugar returns to safe levels...but the establishment taught for decades that grains & carbs are the base of the food pyramid...and if we have learned anything over the last decade, it is that once the establishment settles on a particular narrative, it will defend that narrative with any and all necessary means...thus, the low carb cure for type 2 diabetes has been attacked by establishment forces and their many minions

Listened to a Huberman podcast episode on type 2 diabetes and intermittent fasting and in order to build intuition around my own glucose levels, I started pricking my finger with a lancet ever hour for the last few weeks (going on week 3 now) .... only to discover that I'm actually prediabetic.

I wonder how many others are silently walking around, unaware of their prediabetes.

Almost $1 billion per day in the United States.

And it's mostly type II, not type I.

https://www.cdc.gov/diabetes/data/statistics-report/diagnose...

28.7 million people in the US have diagnosis of diabetes. ~2M are type I, with the remaining 27M being type II.

This updated cost estimate for U.S. diabetics is for 2017, not now. Insulin prices in the U.S. are up substantially since 2017. Another expensive change since then is the increasing availability of the (so-called) continuous glucose monitors, now costing around $100/week for each diabetic using one. My opinion (I use one) is that mine is well worth it, but that the monitors are unlikely to reduce the total medical cost of diabetes care for many because of all the difficulties of responding to the monitor's data with beneficial changes, which might range from immediate doses of food or medication to long-term changes in diet, exercise, lifestyle, etc.

Are CGMs recommended or funded for people with type 2 diabetes in the US?

Mine is paid for by Medicare, but Medicare will only pay for a CGM for type 1 diabetics who actively manage their diabetes based on the CGM data as directed by a physician. For people not covered by Medicare (almost everyone under age 65), I don't know, but I suppose it depends on their insurance company and/or employer, etc, etc, like just about everything. I talk with someone who provides services to diabetics in a low cost clinic funded as a charity for persons with very low income, and they never mention any possibility of getting CGMs for their patients.

Based on my experience with a couple of different CGMs, I guess that the target market of the CGM makers includes many more type 2 diabetics than type 1, both because there are many more type 2 diabetics than type 1, and because the larger number would would yield much more profit; and I also expect that the CGM would generally work better for a type 2 diabetic than my CGMs have worked for me, because my problems with the devices have been caused by fluctuations in blood glucose levels resulting from the sometimes large doses of fast-acting insulin that I take.

What is your take on this situation?

u can cure type 2 if u have it quite easy. i recomend books by jason fung, diabetes code and obesity code.

This is a bit misleading. Yes you can reverse the metrics by which we measure diabetes. But you cannot cure the blindness it may have caused, or the leg amputation that may have been needed, etc... The earlier you begin to manage your insulin spikes, the more likely you are to succeed in "reversing" type 2 diabetes. But I think it's a little presumptuous to call it "easy". Some people have to fast for 3-5 days before their elevated insulin levels begin to drop a little. And even then, they have to do that frequently before their insulin starts to behave somewhat normally. Then when they do eat, they have to be rather careful of what they eat. Not easy, but easier than the alternative.

You can mitigate the effects of Type 2 diabetes. That's not the same thing as curing it. The effects will almost certainly re-occur if you stop the behavior you are using to mitigate it (which is generally low carbs, low calories, exercise, etc).

You can mitigate the effects of a cookie dough induced salmonella infection. That is not the same as curing it. The effects will almost certainly re-occur if you stop the behaviour you are using to mitigate it (which is generally not eating raw cookie dough every single week).

You can go for decades or even a lifetime without remission but the moment you take a bite out of that raw cookie do prepare yourself for a salmonella infection.

That is so ridiculously not the same thing. The point is that Diabetes Type 2 is effectively insulin resistance; your body doesn't use insulin as well as it should (though it's more complicated than that). You can mitigate the effects of this by living a life where you don't need as much insulin (lower card, exercise, etc). But no matter what you do, your body still has a "defect" that causes it to not process (and eventually, generate) insulin as well as someone else.

A better analogy would be a transplant. Just because you are on immunosuppressants to prevent your body from rejecting the new organ doesn't mean you've "cured" yourself of that rejection; you're just mitigating/preventing the impact of it.

My wife has type 1 the Eli Lilly executives are some of the most evil people to ever live. They keep a monopoly on the insulin market, use patents and regulatory capture of the FDA to prevent competition and hurt millions of people.

Eli Lilly doesn't have a monopoly on the insulin market, there are a few big makers like Novo Nordisk and Sanofi.

Generic Novolog is $57/vial at Walgreens according to GoodRx.

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