Now That We Know How To Prevent Diabetes Complications, So How Come So Many People Are Still Getting Them?

Last week I had a very interesting clinic in which the first 3 patients were teenagers with type 1 diabetes.  The first patient was a 16 year old boy with onset of diabetes at about age 6 years.  He was being treated with an insulin pump and had always done extraordinarily well with his diabetes care.  He never missed clinic visits, he tested blood glucose levels 4-6 times daily, he made appropriate insulin dose adjustments, and he never had a hemoglobin A1c over 7% (that’s the test that measures overall blood glucose control during the preceding 3-4 months and is a strong risk predictor for the development of diabetes complications).  The second patient was a 16 year old female with onset of diabetes at age 7 years.  She was being treated with an insulin pump and had always done reasonably well with her diabetes.  She rarely ever missed clinic visits, she tested blood glucose levels 3-4 time daily and usually made appropriate insulin dose adjustments.  Her hemoglobin A1c levels had been consistently in the 7.5-8% range.  The third patient was a 16 year old female with  onset of diabetes at age 9 years.  She was being treated with an insulin pump and had never done particularly well with her diabetes self-management.  She tested blood glucose levels 1-2 times daily at most and not at all on some days.  She had a history of several hospitalizations with diabetic ketoacidosis.  She occasionally missed clinic visits.  Her hemoglobin A1c values had been in the 8.5-9% range up until about age 12 years, and in the 11-12% range thereafter.

Enter the “shadowing” students

That particular clinic day I had 2 undergraduate pre-med students following me around- they call that activity “shadowing,” and the idea is that students can get a feel for  what medicine practice is really like before they actually decide to make a career of it.  One additional practical reason for pre-med students to shadow is that most medical schol admission committees look more favorably on applications that list shadow experiences than those that do not (personally, I wouldn’t think more or less about an applicant based on his or her shadowing experiences).  Anyway, after we had seen the 3 teenagers with diabetes, one of the students asked me why the first patient was doing so well and the last patient so poorly.  It was a great question but I was not able to give a very good answer.  I told the student that I didn’t really understand why some patients with diabetes do so well and others so poorly, even when cared for by the same physician.  We then had quite a long discussion about what is known about patient compliance and why the question was so important in diabetes.

Why Do Patients With Diabetes Develop Chronic Complications?

First, the chronic complications of diabetes can be divided into so-called “microvascular complications,” those of the eyes, kidneys, and nervous system, and “macrovascular complications,” those of the heart and blood vessels.  Although we still have an imperfect understanding of the precise mechanisms responsible for the various complications, we do know  there are 3 principal risk factors involved: blood glucose levels, blood lipid levels, and blood pressure levels.  These risk factors account for approximately 90-95% of the risks for the development and progression of the various diabetes complications.  These risk factors are also treatable and I don’t think I am being overly optimistic when I say that we know how to prevent almost all diabetes complications.  Yet, many patients with diabetes are still developing these devastating complications at enormous personal and societal costs.  So, what gives?  This is really the question that my shadowing student asked.

Over the next few weeks, in a series of entries, I want to explore this question of why some patients with diabetes do better than others.  Perhaps, that is the most important question we should be asking these days in the management of patients with diabetes.  If we can come up with some answers, perhaps, short of a cure, we can have a menaingful impact on long-term outcomes.

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