Glycemic Control and Hypoglycemia: Is the Loser the Winner?: Response to Perlmuter et al.

In their otherwise excellent editorial, Perlmuter et al. (1) make the following statement: “Thus, in both sexes, the warning signs and symptoms of hypoglycemia are typically not exhibited until blood glucose drops to dangerously low levels.” From the context, one should conclude that this sentence is referring to individuals who have nocturnal hypoglycemia or some other form of neuroendocrine desensitization frequently referred to as “hypoglycemia unawareness,” which represents a clear minority of people with type 1 diabetes. The vast majority of people with type 1 diabetes have symptoms well above that threshold and self-treat these symptoms before becoming impaired.

However, as someone who has spent much of his professional career defending the rights of people with diabetes to engage in any occupation for which they are otherwise qualified, I can assure the readers of Diabetes Care that there will be employers who attempt to take this sentence out of context and interpret it to read such that it applies to all people with type 1 diabetes. It could then be used as an excuse to exclude people with type 1 diabetes from a variety of positions, as was the case of Gary Branham, who was excluded from being an IRS special agent until this decision was reversed in court (2).

I urge the editors of Diabetes Care and the authors of the editorial to clarify this statement so that it is clear that the vast majority of hypoglycemic episodes in people with type 1 diabetes are self-treated and do not result in the loss of ability to engage in day-to-day personal or professional activities.