Good News: Type 2 Diabetes

Good News: Type 2 Diabetes

THE UKPDS: GOOD NEWS FOR
PEOPLE WITH TYPE 2 DIABETES

by Richard Hellman, MD.,
FACP, FACE

What the Diabetes Control and
Complications Trial (DCCT) Showed
In 1993, the National Institutes of Health

released the results of a 10-year study of people with type 1 diabetes. The findings of

the study, which is known as the Diabetes Control and Complications Trial, were

extraordinarily encouraging.

Researchers found that among people who
received "intensive treatment:"

* Progression of retinopathy (diabetic eye

disease) was slowed by more than 50 percent;

* Development of nephropathy (diabetic kidney

disease) was decreased by nearly 50 percent; and

* Clinically significant neuropathy (diabetic

nerve damage) was reduced by 60 percent.

Patients whose diabetes was closely managed

learned to adjust their insulin doses to keep blood sugar levels as normal as possible.

Their treatment included at least three injections of insulin a day, blood glucose testing

at least four times a day, and a diet and exercise plan.

Until recently, however, there has not been a

similar large-scale study to answer whether or not people with type 2 diabetes would also

experience positive results from closely managing their disease.

United Kingdom Prospective Diabetes Study (UKPDS)

The UKPDS was the first large-scale longitudinal

study of people with type 2 diabetes that was conducted on the scale of the DCCT. And

since about 90% of people with diabetes have type 2, the results of this study have been

eagerly awaited.

The UKPDS began in 1977 and extended for 20

years, with the results published in the fall of 1998. The study compared conventional

versus intensive therapy in more than 5,000 newly diagnosed patients with type 2 diabetes.

Patients in the study were randomly divided into

three treatment groups, those who were treated with:

* Diet alone;

* Diet plus non-intensive drug therapy; and

* Diet plus intensive drug therapy (using either

insulin, sulfonylureas or metformin), as well as nutrition counseling, exercise therapy

and patient education.

All patients in the study, including those whose

diabetes was closely managed, visited physicians in a regular community setting, rather

than an artificial research environment. So, the medical treatment was provided to

patients by their primary care physicians, with nurses, nutritionists, and others on their

medical teams delivering further support. This is relevant because most people with type 2

diabetes in the U.S. receive their medical care from a primary care physician, as well.

Thus, the findings from the UKPDS study are applicable to American patients with type 2

diabetes.

The major question asked by the UKPDS study was

whether close management of blood glucose levels could substantially reduce the risk of

complications from type 2 diabetes. The results clearly showed that the answer to this

question was a definite YES:

* Close management to keep blood sugar levels

within the normal range reduced by 25% the damage to small blood vessels in the eyes and

kidneys that frequently occurs in people with diabetes.

* Such treatment may also lessen the nerve damage

that can lead to limb amputation.

* Although the study did not prove a direct link

between reducing high blood sugar and a reduction in the incidence of heart disease, it

did find that when blood pressure is reduced, the risk of cardiovascular disease is

significantly lowered. This is important because more than 60% of people with type 2

diabetes suffer from high blood pressure.

One subject that was not addressed by the UKPDS

was the importance of frequent self blood glucose monitoring. Only one group, those

patients on multiple insulin injections, had mandatory glucose monitoring. Although

patients were permitted to do home testing of blood glucose levels, the key therapy

decisions were based on the patients' glucose levels when visiting their doctors. In this

way, the UKPDS was different from both the DCCT study and our own study [see below].

It was clear from the UKPDS study, however, that

reducing blood glucose levels can significantly lessen complications from type 2 diabetes.

In the U.S., frequent self glucose monitoring is an important tool in helping patients

adjust their diet and medication in order to "fine-tune" their control. Thus, if

patients enrolled in the UKPDS study had followed all aspects of close management of

glucose levels as is usually practiced in the U. S., one would expect even greater benefit

in terms of preventing complications.

A U.S. Study on Patients with
Type 2 Diabetes

Although our study, "The Effect of Intensive

Treatment on Risk of Death or Renal Failure in NIDDM or IDDM," was smaller in scope

than the UKPDS, my colleagues and I, at Heart of America Diabetes Research Foundation,

studied both patients with both type 1 and type 2 diabetes. Our study was conducted in a

private setting and showed the value of a more intensive and comprehensive form of therapy

in both types of diabetes.

We followed 209 patients for an average of more

than 11 years and compared their outcomes to a comparable group of 571 patients.

Our long-term patients had a 22% lower death rate

overall and a 40% lower rate of severe kidney failure as well. Even more exciting was the

fact that our lower-risk patients who were under 65 years of age at the start of our study

had a 64% lower death rate, and the type 2 diabetics in this group had a 57% lower death

rate.

Among the differences between our study and the

UKPDS was our greater involvement during critical moments of care, often medical or

surgical emergencies, when control of glucose levels is both most difficult and most

important. Also, we provided early screening for cardiac disease for our patients, an

important and often neglected area of diabetes care.

Also, we used a more intensive and flexible

approach to normalizing the blood sugars, and as a result, were more successful than the

UKPDS study at maintaining good glucose control throughout our 14-year study. Our level of

glucose control overall was nearly as good as the results achieved by the DCCT study.

We view self-blood glucose monitoring as an

essential ingredient for quality care for several reasons. It provides important feedback

for both patient and physicians, so therapy can be tailored to the individual patient

needs and allow a more flexible life-style.

Also, it becomes a "safety net" since

important and unexpected changes in blood sugar levels are, unfortunately, far too common

and often without any accompanying symptoms. Self-blood glucose monitoring is truly a

patient safety issue.

Steps the Patient Can Take

Sadly, many patients with type 2 diabetes are not

receiving the level of treatment they require to help prevent complications from the

disease. Because of the burdens on today's medical system, doctors are often hindered from

spending as much time as they might wish on disease management. In addition, some states

and insurance carriers place limits on financial reimbursement for diabetes education and

testing materials.

One good piece of recent news is that Medicare

now covers the cost of blood glucose meters and strips for patients with type 2 diabetes,

whether or not they are taking insulin. (Previously, reimbursement was limited only to

patients on insulin therapy.) Furthermore, Medicare is expected to enact legislation that

will reimburse patients for the education they need in order to learn how to manage their

disease.

For patients with type 2 diabetes who may not be

receiving the support they need to closely manage their disease to help prevent

complications, the following are important steps to take:

* Make certain you are being treated by a health

care professional who makes a commitment to diabetes disease management. If the doctor

hasn't already suggested that you meet with a diabetes educator and nutritionist, ask for

referrals.

* Working with health care professionals, follow

their advice regarding diet, exercise, blood glucose monitoring and medication.

* Learn what steps you can take (relating to diet

and/or medication) if your blood sugar levels fluctuate out of the normal range.

* Seek referral to a specialist if your
doctor isn't taking your symptoms seriously enough.

The future is brighter than ever for people with

type 2 diabetes. Although close disease management can be complicated and is

time-consuming, patients should be heartened by the fact that such treatment is now of

proven value. The goal of all doctors treating patients with type 2 diabetes should be to

significantly reduce the incidence of complications from the disease and to provide a

long, vital, and enjoyable life for all patients.

NOTE: Dr. Hellman is Clinical Professor of

Medicine at University of Missouri, Kansas City, where he is also an endocrinologist and

diabetes specialist in private practice. His articles have been published in "New

England Journal of Medicine" and "Diabetes Care." He has served in numerous

national positions within the American Medical Association and the American Diabetes

Association.