THE
SAD STATE OF DIABETES CONTROL IN AMERICA
A
study was recently published comparing patients with Type 2 Diabetes who are
attending Endocrine Clinics in North America, for a study to compare usual care
to that included Continuous Glucose Monitoring.
At
the end of six months, the USUAL care, which I would imagine is the best care
Endocrinologists and the Diabetes team was able to give in private practice,
the HbA1c decreased by 0.5%, just half a point!
This
is part of a study and we all know that when not under study conditions, the
results tend to be half the published one, so in effect the Endocrine Care of
these patients with obviously a Nutritionist, Diabetes Educator plus others
made very little difference in the outcome.
Who
were the patients?
158 adults who had had type 2 diabetes for a median of 17 years (interquartile range, 11 to 23 years). Participants were aged 35 to 79 years (mean, 60 years [SD, 10]), were receiving multiple daily injections of insulin, and had hemoglobin A1c (HbA1c) levels of 7.5% to 9.9% (mean, 8.5%).
I decided to access the original article published in the
Annals of Internal Medicine. Most of the practices studied were in the USA (3
in Canada) and in private practice clinics.
Patients who were receiving Usual care were predominantly
white, 77 per cent whereas those they were being compared to (wearing a
continuous glucose monitor device) were only about 50 per cent white and the
rest being from the minorities. Half the patients had A1C between 7-8.5 and the
other half between 8.5-10.
The academic institutions were Joslin in Boston, Washington
University in St Louis, the Universities in Portland and Seattle: all heavy
hitters in the field of Diabetes care and treatment.
Usual care was being compared to people wearing Continuous
glucose monitoring device and the authors consider the difference in CGM
wearers a success since a reduction of just 0.3% in HgbA1c is considered a
“success”
Among the people I work with, the Native Americans of
Nebraska, people walking round with an A1c of 9% is not at all uncommon, so for
us a drop of 0.3% is not a success and I am sure this is the case among many
poor and marginalized communities of Hispanic and Black Americans with
Diabetes.
So for those of us working with Native Americans, we should
be proud of our efforts, which is a Psychosocial Model emphasis on Education
with intermittent consultation with a visiting Endocrinologist. The Omaha Model
as it is called, has produced results much better than the ones published in
this article. I liked the article and it is well done and well written but the
irony is not seen: even with best MEDICAL attention, the A1c reduction was
negligible. I am more than ever convinced that Type 2 Diabetes is a SOCIAL
ILLNESS and the best results are when it is approached holistically with
Diabetes Educators working in close cooperation with community operatives with
intermittent consultations with an Endocrinologist.
In the Omaha Model, success is further guaranteed by the open
minded Primary Care Providers who work in conjunction with the Diabetes
Educator and Peer to Peer Educator.
ORIGINAL RESEARCH |22 AUGUST 2017
Continuous Glucose Monitoring Versus Usual Care in
Patients With Type 2 Diabetes Receiving Multiple Daily Insulin Injections: A Randomized Trial
Roy
W. Beck, MD, PhD; Tonya D. Riddlesworth, PhD; Katrina Ruedy, MSPH; Andrew
Ahmann, MD; Stacie Haller, RD, LD, CDE; Davida Kruger, MSN, APN-BC; Janet B.
McGill, MD; William Polonsky, PhD; David Price, MD; Stephen Aronoff, MD; Ronnie
Aronson, MD; Elena Toschi, MD; Craig Kollman, PhD; Richard Bergenstal, MD; for
the DIAMOND Study Group (*)
Ann Intern Med. 2017; doi: 10.7326/M16-2855
