A Systematic Approach to Diabetes Management in the Post-DCCT Era

Abstract

A s with the discovery of a new wonder drug, the reporting of a major new clinical trial is usually followed by a three-step adjustment period in the collective attitudes of the health-care profession and the general public. There is initial euphoria that this is the answer, the panacea, i.e., the treatment for everyone. These feelings are followed by a rebound response of despondency that the side effects and problems with the new treatment are too serious and that the treatment is too costly and complex to make it useful at all. Finally, a rational place for the new discovery is found in medical practice.In the case of the Diabetes Control and Complications Trial (DCCT), many people are still fluctuating between stages 1 and 2. On the one hand are people who feel that everyone with diabetes should be given intensive therapy, that we need more education programs, and more educators and therapeutic evangelists to persuade and cajole all patients with diabetes to push their HbA lc as close to normal as humanly possible. On the other hand are people already at stage 2 (some of whom were never at stage 1) who have a long list of criticisms, including the belief that the DCCT did not show anything new that was not addressed in many previous smaller studies on the same issue; that you cannot extrapolate from this very select group of participants to other people with diabetes; that the results will not change clinical practice anyway, because trying to get blood glucose levels as low as possible is what everyone tries to do already; that the side effects of hypoglycemia and weight gain are barriers that cannot be overcome; that you cannot improve control in most patients because they will not comply; and that the costs of improving control are unrealistically high, etc.In this commentary, we would like to present a practical, clinical, behavioral, educational, and health-care delivery perspective on the DCCT and recent related studies. Specifically, we will discuss whether the approach to diabetes management should be different now, and if so, how this new approach should be implemented in the real world of escalating health-care costs, shrinking resources, and impending health-care reform.

Standards of Medical Care in Diabetes—2007

“…There are opportunities for the clinician to assess psychosocial status in a timely and efficient manner so that referral for appropriate services can be accomplished (79). Key opportunities for screening of psychosocial status occur at diagnosis, during regularly scheduled management visits, during hospitalizations, at discovery of complications, or at the discretion of the clinician when problems in glucose control, quality of life, or adherence are identified (80). Patients are likely to exhibit psychological vulnerability at diagnosis and when their medical status changes, i.e., the end of the honeymoon period, when the need for intensified treatment is evident, and when complications are discovered (75,77).…”

“…Screening tools can facilitate this goal, and although the clinician may not feel qualified to treat psychological problems, utilizing the patient-provider relationship as a foundation for further treatment can increase the likelihood that the patient will accept referral for other services. It is important to establish that emotional well-being is part of diabetes management (80).…”

“…Psychosocial screening should include but is not limited to attitudes about the illness, expectations for medical management and outcomes, affect/mood, general and diabetes-related quality of life, resources (financial, social, and emotional) (76), and psychiatric history (77,80,81). Particular attention needs to be paid to gross noncompliance with medical regimen (due to self or others) (81), depression with the possibility of self-harm (73,74), indications of an eating disorder (82) or a problem that appears to be organic in origin, and cognitive functioning that significantly impairs judgment (74).…”

Healthy lifestyle interventions in general practice Part 4: Lifestyle and diabetes mellitus

“…38 The general practitioner and family physician are well positioned to support their patients emotionally through attentive and active listening which allows patients grappling with the effects of living with a chronic illness to feel seen and understood.…”

The Translating Research Into Action for Diabetes (TRIAD) Study

“…Because of the proliferation of managed care systems, with various organizational, reimbursement, and disease management approaches (13)(14)(15)(16)(17)(18)(19)(20), managed care is a critical setting in which to apply this paradigm. The TRIAD study is a multicenter prospective study that seeks to identify modifiable barriers to optimal diabetes care across diverse managed care settings.…”