Over the past 2 years, I have often written about the need to care for type 1 diabetes with a "team approach." As a pediatric diabetologist, 90 percent of my practice consists of children, teens, and young adults with type 1 diabetes. What about the other 10 percent of children/teens and young adults with type 2 diabetes? Lifestyle change, particularly diet and exercise, is extremely difficult to alter especially when perceptions of type 2 diabetes differ from those of type 1 diabetes. (T2DM is erroneously viewed as less serious since it can be treated, at least initially, with oral medications along with lifestyle moderation.) We have found that it is often very difficult to successfully care for the 10 percent of patients with T2DM in our practice due to the above perceptions. Despite our "team" approach at Children's National Medical Center (physicians, nurse educators, dieticians, psychologists, social workers), we still have significant challenges to improve T2DM care.
I was somewhat heartened when I reviewed an abstract (108) "Achieving ABCs of diabetes care with ‘a team of four approach," presented by S. Varma et al. at the 2010 World Congress on Insulin Resistance (WCIR). According to Dr. Varma of The University of Pittsburgh School of Medicine, patients, families, doctors, and staff, make a significant difference in gaining control of type 2 diabetes in people 18 years or older. This information should not be surprising in view of my experience in pediatrics with the type 1 DM population. However, it makes perfect sense to apply the same successful team approach to adults with T2DM. According to Dr.Varma, by successfully integrating all parties in treatment, more T2DM patients were able to achieve goal hb A1c's, blood pressures, and LDL levels. In Varma's study, 396 patients used the "Team of 4" approach. The results over five years were as follows.
- 42 percent of patients had hb A1c's of less than 7 as compared to 30 percent at baseline (keep in mind that these goals are for people with T2DM, NOT T1DM).
- 58 percent improved LDL to less than 100, whereas at baseline only 35 percent were at that level.
- 62 percent of people had BPs of less than 130/80 compared with 45 percent at baseline.
In summary: 18 percent of patients achieved all three goals as compared to 5 percent at baseline. (These results were statistically significant.) Thus, Dr. Varma concluded "the study showed a team approach makes it possible to achieve better than average with our patients." (Keep in mind that this is just a pilot study that needs to be further expanded with future results published in a peer -reviewed journal.)
How does this relate to my children and teens withT2DM?
If we improve the treatment in the T2DM adult population, perhaps we then may make major inroads in our pediatric T2DM population who most often have members of the family with T2DM. It has always been my belief that to decrease the incidence of type 2 Diabetes in children at risk for the disease due to a familial inheritance pattern, one must make major behavioral changes very early in the environment. Sobering 2007 statistics from the American Diabetes Association reveal "about 2 million adolescents aged 12-19 have pre-diabetes." A recent (February 2010) multivariate analysis in The Archives of Pediatrics and Adolescent Medicine, by Dr. Gerald Berenson of Tulane University, demonstrated that children and adolescents with fasting blood sugars greater than 85 mg/dl have an increased risk of developing prediabetes (p<0.001) and Type 2 diabetes (p=0.03) in adulthood. A "sea change" must occur to decrease the epidemic of type 2 diabetes in our children (even at 8 years of age), teens, and young adults.
I propose that we implement a form of the "Team of 4 Approach" directly into the family unit (and communities) before children and young adults become insulin resistant and pre-diabetic. In this way, by improving the care of the adults with T2DM and hopefully modifying behavior in the other family members, perhaps we could slow down the T2DM epidemic. More evidence-based research is required to determine the most efficacious approach to improving the care of adults with type 2 diabetes and ultimately preventing the development of pre-diabetes and T2DM in our children/teens and young adults.
Published On: December 07, 2010