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Diabetes is one of the leading causes of death in the United States, but not talked about enough. The Centers for Disease Control and Prevention states that 37 million Americans have diabetes and 1 in 5 people don't know they have it. "In the last 20 years, the number of adults diagnosed with diabetes has more than doubled as the American population has aged and become more overweight or obese," the CDC says. Diabetes is a major health concern and when left unmanaged, it can become deadly. Dr. J. Wes Ulm , Harvard/MIT-trained MD/PhD with a background in bioinformatics, gene therapy, genetics, drug discovery, consulting and education explains to Eat This, Not That! Health diabetes signs that indicate a life-threatening case, but as always please consult your physician for medical advice. Read on—and to ensure your health and the health of others, don't miss these Sure Signs You've Already Had COVID .

1 How Can Diabetes Become Life Threatening?

Dr. Ulm says, "Diabetes can be life-threatening both acutely (with a markedly high blood sugar level sufficient to cause diabetic ketoacidosis) and chronically (as a result of cumulative organ and tissue damage from chronically elevated blood glucose levels). First it's important to note that there are several types of diabetes mellitus (i.e. diagnosed based on chronically elevated glucose levels in the blood), and two that are most important clinically: Type 1 and 2, as well as gestational diabetes (manifesting in some women during pregnancy). Type 1 diabetes is an autoimmune disease, taking shape when an important subset of lymphocytes (a type of white blood cell) in our immune system — T-cells — becomes 'misprogrammed' so as to attack the Islets of Langerhans (the beta-islet cells, to be specific) within our pancreas which produce the hormone insulin. Without circulating insulin, many cells within the body — particularly muscle cells and fat cells (about 60-70% of our cells, in fact) — can't properly 'dock' the glucose receptors (primarily a molecule called GLUT4) that allow them to take in the primary sugar circulating in the blood. Type 2 diabetes is something like the 'flip side' of Type 1; here, the Islets of Langerhans are intact and making insulin, but for complicated reasons, the cells that take up glucose are less sensitive to the hormone, and so don't take up the blood glucose as effectively. It normally presents in adults, but is increasingly being seen in children as well particularly in the setting of childhood obesity.

Type 1 diabetes is the form that usually presents in childhood and, in fact, its initial presentation is frequently diabetic ketoacidosis (DKA), which can be acutely life-threatening. Without diving into too much detail, patients and especially kids with undiagnosed Type I diabetes can develop extremely high glucose levels while, at the same time, their liver outputs acidic substances called ketone bodies, which you can think of as a kind of fatty "sugar substitute" in the blood to fuel muscles and other tissues that can't take in the sugar. The high sugar, in turn, induces disruptions to kidney filtration, leading to a phenomenon called 'osmotic diuresis' with excessive urination that causes the blood to lose large quantities of critical electrolytes (salts) in the urine, particularly sodium and especially potassium. So children especially will often present in a very sick state at the emergency room with vomiting, hyperventilation or other altered breathing (in a form called Kussmaul respiration when severe), abdominal pain, dehydration, and potentially confusion and faintness. Both the high blood acidity and dysregulation of potassium can be directly life-threatening in three ways in particular. The elevated acid in the blood (what we call a metabolic acidosis, hence 'ketoacidosis'), dehydration, and disrupted potassium levels — usually too low (hypokalemia) as a result of the excessive urination, but occasionally too high — can interfere with the heart's electrical activity and rhythms. They can also cause damage to the central nervous system (a likely factor in the confusion that many present with), and in combination with excessive exhalation of carbon dioxide (from the hyperventilation), can lead to a dangerous phenomenon called cerebral edema, essentially when there's too much fluid on the brain. Type 2 diabetes usually doesn't present with DKA, but it can be associated with another dangerous acute condition — called hyperosmolar hyperglycemic state (HHS) — which presents with many of the same life-threatening complications as DKA (along with excessive clotting), and with many common elements in its management.

Chronically, both types of diabetes can be life-threatening as a result of several kinds of organ damage that's caused by chronic overabundance of circulating glucose. Without diving too deeply into the mechanisms, the elevated blood sugar gets converted into toxic substances like sorbitol and advanced glycosylation end products (AGEs) that can damage both small and large blood vessels, the kidney, the retina, and the nerves around them, engendering many of the deleterious symptoms and chronic diseases (such as coronary artery disease, renal failure, as well as numbness and tissue damage from impaired sensation) when glucose is poorly controlled. Type 2 diabetes is also associated with a condition called metabolic syndrome, which is likewise linked with enhanced risk of a number of chronic illnesses that can be life-threatening if untreated."

2 Why Diabetes Oftentimes Goes Unnoticed

As mentioned earlier, 1 in 5 people don't know they have diabetes, according to the CDC and Dr. Ulm explains, "This happens in large part because elevated blood sugar (i.e. hyperglycemia), like high blood pressure (hypertension), is a "silent sign" — it often doesn't manifest symptomatically, in a way that makes a patient aware of it. Blood sugar is regularly screened and thus excessive serum glucose can be detected through a general blood workup, as part of a routine general checkup and medical follow-up. Tragically, however, many Americans in particular lack health insurance, or may find it difficult to miss work for a visit with their PCP or other physician, and thus may lack timely doctor's visits to monitor such issues. For this reason, if they don't have symptoms from elevated blood glucose — and most don't, aside from fairly nonspecific symptoms (such as a yeast infection) — they simply won't be aware of the problem, and may fail to manage it until the toxic products above start to wreak damage on tissues. To be clear, such 'silent hyperglycemia' is principally a problem with Type 2 diabetes — which, again, results from insulin resistance (when peripheral tissues don't respond enough to the hormone in the blood) — and which tends to me more indolent and less pronounced than Type 1 diabetes. The hyperglycemia in Type 1 tends to be much more drastic in the period before a patient is diagnosed, and thus is often more evidently symptomatic with excessive urination, thirst, and appetite (the first two resulting from the effects of the high blood glucose on the kidneys)." 6254a4d1642c605c54bf1cab17d50f1e

3 Signs That Indicate You Could Have Life-Threatening Diabetes

Dr. Ulm shares, "When diabetes is acutely life-threatening, it can often signify a dangerous condition like DKA or HHS as described above. Look for indicators of dehydration and physiological dysregulation such as constant severe thirst or excessive urination, overwhelming hunger, or abdominal pain which can be a sign especially of significant hyperglycemia in Type 1 diabetes. If DKA or HHS are threatening, then a patient (children in particular) will manifest with more pronounced symptoms like confusion and/or lethargy, exacerbated abdominal pain, vomiting, and marked hyperventilation. These conditions resulting from severe hyperglycemia can be quite dangerous and, as noted, threaten vital organs such as the heart and central nervous system, thus it's essential to get a potential patient to a medical facility immediately to evaluate for potential DKA, HHS, and other serious manifestations of highly elevated blood sugar."

4 How Diabetes Can Affect Your Overall Health

Dr. Ulm states, "As described in the answer to the first question above, uncontrolled or poorly managed diabetes can have both acute and chronic effects. Acutely it can give rise to life-threatening conditions if the blood glucose gets too high, but chronically, it can be a persistent health condition that gradually and repeatedly injures vital organs, particularly the kidneys. That's why aggressive glucose control is so important."

5 How To Help Manage Diabetes

According to Dr. Ulm, "As a chronic condition, diabetes requires constant vigilance, and especially for children with Type I diabetes, this means intensive parental involvement and regular medical checkups. Because Type 1 diabetics either lack insulin entirely or have minimal levels (due to autoimmune attack and effacement of most beta-islet cells), they have to be particularly wary to avoid wide swings in blood glucose that could lead to DKA or hypoglycemia, which can also be dangerous. In the past, careful glucose monitoring generally meant multiple daily finger sticks to measure the glucose levels, but fortunately, technology has advanced significantly to make regular blood glucose monitoring through wearable devices more practical. These systems utilize a disposable skin patch as a sensor, providing critical analytical information on fluctuating blood glucose levels without need for skin pricks. Suppliers such as Dexcom, Medtronic, and FreeStyle Libre alongside a number of smaller manufacturers have made an increasing array of such devices available, and their accuracy continues to improve. Daily measurements are coupled with subcutaneous (beneath the skin) insulin injections according to a doctor's instructions to make sure the blood sugar stays in a well-controlled range, with some of the newer blood glucose monitors also helping with the insulin administration. There are significant research efforts currently underway to develop novel therapies such as beta islet cell transplants (as well as concomitant improvements for Type 2 diabetes), so potentially more permanent solutions may be looming on the horizon.

For Type 2 diabetics, such intensive daily monitoring is usually not required, but it's still essential to maintain blood glucose in the prescribed range as much as possible. Since Type 2 patients lack insulin sensitivity instead of production (i.e. their pancreatic Islets of Langerhans cells are still making insulin), doctors will prescribe them a variety of medications and drug classes — such as metformin, sulfonylureas, and thiazolidinediones — that help via mechanisms like reducing insulin resistance, thereby making diabetics' tissues more responsive to insulin. It's important to take these medications on the prescribed schedule, and to follow general health and wellness guidelines, particularly with regard to dietary improvements and weight reduction where needed, to mitigate both the diabetes itself and its adverse health effects. To help better maintain their proper blood sugar levels, both Type 1 and Type 2 diabetics will also undergo a test for a substance called hemoglobin a1c, which functions as a sort of marker for how well glucose has been controlled over a longer period over weeks and months. (It's also used to help confirm an initial diabetes diagnosis.) 

An additional salient note on this topic is that COVID-19, concerningly, has been found to be associated with substantial increase in the risk of both types of diabetes arising in an affected patient. This is true even for mild cases in healthy children, and may be another of many manifestations of long COVID syndrome. Although doctors and scientists are still hashing out the basics of how COVID enhances diabetes risk, it's become clear that increases in the sheer quantity of viral particles with a COVID exposure are a factor in causing disease. Thus masks, vaccines, boosters, good air filtration, ventilation, case tracking, and social distancing, while imperfect, contribute greatly to tangible reductions in the viral load (i.e. the viral dose or inoculum) that a person takes in upon an exposure to the coronavirus. These precautions therefore lessen the risk of severe disease states including hypercoagulability (too much clotting, with related risks such as that for pulmonary embolism), heart disease, and of course diabetes, which again are more frequent in the aftermath of even mild COVID cases."

Wes Ulm, MD, PhD, is a physician-researcher, musician (J. Wes Ulm and Kant's Konundrum), and novelist, and earned a dual MD/PhD degree from Harvard Medical School and MIT. He is part of the Heroes of the COVID Crisis series in relation to his ongoing efforts in the drug discovery and public health arena.

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