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Thu Sep 17 14:05:59 UTC 2009

Finding flaws in landmark diabetes trial vs. real life » Corpus Christi Caller-Times

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Patients struggles with maintaining good management of diabetes not something medicine can control
 a.. By Dr. Stephen Ponder 
  b.. Posted September 16, 2009 at 10:57 a.m. 
  a.. Email a.. Discuss a.. Share » a.. Digg a.. Facebook a.. LinkedIn a..     MySpace a.. Print a.. A a.. A a.. A CORPUS CHRISTI — One reason we need a real cure for diabetes is that most diabetics have trouble maintaining good management of their diabetes for reasons that modern medicine can’t really change. 

The landmark Diabetes Control and Complications Trial proved the virtues of tight blood sugar control. Yet it took a decade to conduct (1983-93) and required near superhuman effort to keep 1,440 people with Type 1 diabetes in consistent diabetes control over that entire time. 

But the real story behind the trial is what still haunts us today. It’s our inability to apply its conclusions and recommendations into the lives of millions. 

We never have been able to duplicate its results on a large scale. It has been said that only 5 percent of diabetic patients now can possibly attain and sustain the levels of control shown in the trial.

Patients in the trial were between 13 and 39 at the start of the study. That meant that applying the results to patients outside those ages would not be scientifically defensible. Yet, I see that being done now by pretty much everyone in the profession.

Next, (and this is the trial’s real dirty little secret) all study patients were screened for any pre-existing mental health or social conditions that would keep them from being able to maintain good control. If I had the ability to pick and choose like that in the real world, my clinical outcomes would look fantastic too. But the world is full of poorly motivated, mentally/socially challenged and frankly mentally ill adults and children who just happen to have diabetes too. Where do they fit in this model of diabetes health care delivery? They don’t.

Everyone in the trial was provided diabetes supplies at no cost to them. When we consider the high costs of daily diabetes care now, this becomes a significant financial barrier to good outcomes. In the discussions about health care reform resulting from tens of millions of uninsured Americans, diabetes ranks high on the list of financially crippling diseases that often gets neglected simply because there is no way to pay for the proper care and equipment, or the education needed to manage it each day.

Finally, (and this also speaks to resource allocation) consider that trial patients in the treatment group (aimed at keeping the blood glucose average low) all got monthly visits to the diabetes doctor and weekly calls from the diabetes nurse to make constant adjustments in their daily management. Communication was almost always by phone or fax. In that regard, the trial was the first study to really prove the value of telemedicine and diabetes care outcomes on such a grand scale. And this was accomplished well before cell phones, text messaging, computers and the Internet permeated our lives.

Ultimately, the trial represents a search for a Holy Grail: perfecting blood sugar control and lowering the long term complications of diabetes. In the end, the power to succeed over diabetes lies in every one of us. The trial proved it could be drawn out in a select few. But as our natural riches may be buried at different depths within the ground below, how deep do you and other have to drill down to unleash it within you?

Dr. Stephen Ponder, who has Type 1 diabetes, has been a pediatric endocrinologist for 20 years. He is director of the Children’s Diabetes and Endocrine Center of South Texas at Driscoll Children’s Hospital. Contact him at 694-4864 or stephen.ponder at dchstx.org or follow him on Twitter at twitter.com/dr_steve_ponder

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