Many of my friends and colleagues have been shocked and saddened by the recent deaths of actor Farrah Fawcett and musician Michael Jackson. Fawcett's struggle was against a relatively rare form of cancer -- a sadly painful decline, but straightforward in cause and effect. At this writing, the cause of Jackson's death is being reported as "cardiac arrest". Much like Type 2 diabetes, the clinical event can have a number of underlying causes; like Type 1, it can have a number of lead-in events.

We know that both genetic and lifestyle factors play large roles in both heart disease and Type 2 diabetes. A few years ago, I lost a close friend at age 42 from a series of heart attacks resulting from a congenitally malformed heart. Last year, one of my renfaire colleagues had a milder heart attack of which undiagnosed Type 2 diabetes may have been a factor. In a number of causes of sudden death, the last fatal blow is when injury to the heart or the blood vessels, or lack of oxygen to the heart muscle, cause the heart to pump irregularly, and then finally, cease pumping. In short, "cardiac arrest" can describe cause-of-death about as accurately as "tragedy" can describe "The Scottish Play", or Romeo and Juliet.

Conversely, just as many paths can come to a single fatal endpoint (cardiac arrest), a single author can pen many causes of death. Coming back to Shakespeare, we see death make it's appearance by the use of a number of different poisons, stabbings by knife and sword, drowning, strangulation, beheading...

So too does Diabetes author many modes of death. In brief, ketoacidosis, cardiac arrest, stroke. In the longer form, chronic cardiovascular disease, heart disease, kidney failure, gangrenous infection, and increased danger from everyday communicable diseases. While publicly, we may be given to understand that someone with diabetes who has had a lingering death may have "died from complications of diabetes", those to whom Diabetes has authored a more rapid demise may find its signature missing from the death certificate. (Again, "cardiac arrest" is the fatal event, not the underlying cause.)

Perhaps this is because we look for the fast answers, rather than the deep ones, so our coroners and medical examiners do not look for diabetes' hand behind the arras, the author penning, and the puppeteer manipulating, the storyline of the more obvious disease. The device is worthy of Rube Goldberg, with a storyline as twisted as Shakespeare, and clues missed by Dr. Watson but so blatantly obvious to Sherlock Holmes.

Diabetes -- whether obvious or anonymous -- is truly the devious author of our demise.