mercredi 30 août 2017


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.

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