Type 1 diabetes therapy: Is there a best approach?

Dr. Fran Cogen Health Pro

    I am on service today covering the diabetes practice at The Children’s National Health System. As such, between answering phone calls and caring for patient needs, I am catching up on my journal reading. One particular article from Pediatric Diabetes 2013: 14: 473-480 written by F. Cameron et. al and the Hvidoere International study group piqued my interest. The Hvidoere International study group on childhood diabetes evolved in 1994 after the results of the DCCT were available. The group was developed to discuss strategies that could “improve the quality of pediatric diabetes care and thereby improve subsequent adult outcomes.” The group consists of 26 pediatric diabetes centers from 23 countries including those in Europe, North America, Japan, and Australia. Five major studies have been concluded resulting in major lessons revolving around quality of life based on validated questionnaires.  The group delineated four lessons learned regarding the care of children with diabetes.

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    1. Frequent scheduled clinical medical contact is more effective in improving metabolic control than crises intervention. 24-hour telephone support should be available. (No surprise)


    2. For individual physicians: it’s not what you do, it’s how you do it!  According to the study group, it appears that the “way in which staff at a center apply a given insulin regimen is more important in determining metabolic outcomes that the regimen itself !” There are studies that have reported a lack of association between specific insulin types and regimens and metabolic outcomes. (Comment:  I have reiterated in previous blogs the following statement by the authors). “The success of even the most sophisticated of insulin regimens combined with continuous glucose sensing still remains hostage to issues of patient adherence and usage.” In summary, despite the proven evidence-based advantages of intensive insulin therapy in association with CGM, intensifying an insulin regimen does not necessarily guarantee improvement in glycemic status. The authors go on to conclude:  “clinical and metabolic goals or targets that the accompany any therapeutic regimen are more important in determining outcomes.”


     3. For diabetes team members: “unanimity of purpose is everything!” Hb A1c targets and team communication with families with improved family functioning were more strongly associated with metabolic outcomes when compared to “small picture issues such as insulin type, insulin delivery, types of insulin adjustment, and variations in hypoglycemia management.” Hence the importance of continued psychological research aiming at improving communication amongst family members, improved quality of life and adherence.


    4. For Families: “effective teamwork wins the day.”  Our diabetes psychosocial team, as well as many other investigators, have noted that families where both parents are living or coparenting together, along with employment had better metabolic outcomes. Much research is looking into how to improve glycemic status in families at high risk in terms of functioning and socio-economic status.  In addition, our group and others have noted that parental, specifically maternal, well-being is essential to improve metabolic control. Targeting just the child with diabetes is not enough; rather attention should be focused on the entire family unit.


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    The study group concluded that the “one size fits all” approach to diabetes care in both children and adolescents does not work!  “It appears that the best results will be obtained by diabetes teams that are target-driven with a unanimity of purpose.” They summarize with the following statement: Be dogmatic about outcome but flexible in approach.


    Application: Insulin is the appropriate medication for children and adolescents with diabetes.  The particular chosen regimen (conventional split mixed insulin 2-3 shots/day, premixed insulin 2 shots/day, multiple daily injections with basal and bolus insulin, insulin pump therapy in association with continuous glucose monitoring) is only effective if the child with T1DM and family are totally on board and willing to communicate and work effectively with the diabetes healthcare team. Psychosocial support is essential to sustain good quality of life and family functioning.





Published On: February 19, 2014