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Editor’s viewpoint: Changing diabetes care on a cosmological scale

David Kerr

‘In the beginning the Universe was created. This made a lot of people very angry and has been widely regarded as a bad move.’ – Douglas Adams

Increasingly, I am convinced that there are a number of parallel universes, certainly in diabetes. Over recent years one of the main directions of care for people with type 1 diabetes has been the development of programmes of education. These have predominantly focused on teaching principles of insulin dose adjustment related to food and other aspects of so-called ‘normal’ living and, as such, have become something of an industry. Now, no self-respecting diabetes centre should be without one…! In truth, the concept of intensive education in type 1 diabetes has been around for a considerable time (Muhlhauser et al, 1983).

More recently, there seems to have been both controversy and not a small amount of angst about whether one programme is better (whatever that means) than others and therefore should be the only true way. To some, structured education and diabetes are so intertwined that it is almost sinful not to have experienced a quality-assured programme, yet it is clear that there are some patients who do quite nicely, thank you, without one. There are also other individuals who simply do not benefit from their participation in an education programme (Naik et al, 2005).

At the same time, enthusiasts for insulin pump therapy (including your Editor) have become more and more persuaded that, for certain individuals with type 1 diabetes including children, this mode of insulin delivery offers distinct advantages over multiple injection therapy (and structured education per se), particularly if hypoglycaemia has been a major problem (Linkeschova et al, 2002). The two universes of education and pump therapy seem to have been evolving in parallel with distinct boundaries being maintained between them.

It now seems that the time for a ‘big bang’ has arrived, where the parallel universes need to combine to create a more coherent and sensible pathway for patients to travel according to need – this universe should be on offer to patients irrespective of where they live.

Recently there has been some good news which needs to be more widely appreciated – evidence indicates that rates of microvascular complications associated with type 1 diabetes are on the decline (Rossing, 2005). Perhaps now attention needs to turn to dealing with the excess cardiovascular mortality associated with the condition (Soedamah-Muthu et al, 2006).

This brings me to the third parallel universe – to any visiting aliens, it may appear that the only subject in town with respect to type 2 diabetes is reducing cardiovascular risk. Although clearly important, in the South coast of the Albion it is almost impossible to find individuals whose only problem is type 2 diabetes. Here, one needs to be an expert on ageing, cognitive impairment, multiple pathology, immobility, loneliness, terminal illness and misery as well as diabetes – I guess that is what makes each day different and perhaps why specialists are not an endangered species and why annual reviews should be left to others…

‘In the beginning the Universe was created. This made a lot of people very angry and has been widely regarded as a bad move.’ – Douglas Adams

Increasingly, I am convinced that there are a number of parallel universes, certainly in diabetes. Over recent years one of the main directions of care for people with type 1 diabetes has been the development of programmes of education. These have predominantly focused on teaching principles of insulin dose adjustment related to food and other aspects of so-called ‘normal’ living and, as such, have become something of an industry. Now, no self-respecting diabetes centre should be without one…! In truth, the concept of intensive education in type 1 diabetes has been around for a considerable time (Muhlhauser et al, 1983).

More recently, there seems to have been both controversy and not a small amount of angst about whether one programme is better (whatever that means) than others and therefore should be the only true way. To some, structured education and diabetes are so intertwined that it is almost sinful not to have experienced a quality-assured programme, yet it is clear that there are some patients who do quite nicely, thank you, without one. There are also other individuals who simply do not benefit from their participation in an education programme (Naik et al, 2005).

At the same time, enthusiasts for insulin pump therapy (including your Editor) have become more and more persuaded that, for certain individuals with type 1 diabetes including children, this mode of insulin delivery offers distinct advantages over multiple injection therapy (and structured education per se), particularly if hypoglycaemia has been a major problem (Linkeschova et al, 2002). The two universes of education and pump therapy seem to have been evolving in parallel with distinct boundaries being maintained between them.

It now seems that the time for a ‘big bang’ has arrived, where the parallel universes need to combine to create a more coherent and sensible pathway for patients to travel according to need – this universe should be on offer to patients irrespective of where they live.

Recently there has been some good news which needs to be more widely appreciated – evidence indicates that rates of microvascular complications associated with type 1 diabetes are on the decline (Rossing, 2005). Perhaps now attention needs to turn to dealing with the excess cardiovascular mortality associated with the condition (Soedamah-Muthu et al, 2006).

This brings me to the third parallel universe – to any visiting aliens, it may appear that the only subject in town with respect to type 2 diabetes is reducing cardiovascular risk. Although clearly important, in the South coast of the Albion it is almost impossible to find individuals whose only problem is type 2 diabetes. Here, one needs to be an expert on ageing, cognitive impairment, multiple pathology, immobility, loneliness, terminal illness and misery as well as diabetes – I guess that is what makes each day different and perhaps why specialists are not an endangered species and why annual reviews should be left to others…

REFERENCES:

Linkeschova R, Raoul M, Bott U et al (2002) Less severe hypoglycaemia, better metabolic control, and improved quality of life in Type 1 diabetes mellitus with continuous subcutaneous insulin infusion (CSII) therapy; an observational study of 100 consecutive patients followed for a mean of 2 years. Diabetic Medicine 19(9): 746–51
Muhlhauser I, Jorgens V, Berger M et al (1983) Bicentric evaluation of a teaching and treatment programme for type 1 (insulin-dependent) diabetic patients: improvement of metabolic control and other measures of diabetes care for up to 22 months. Diabetologia 25(6): 470–6
Naik S, Everett J, Jenkins E et al (2005) Why doesn’t intensive education work for some people with type 1 diabetes? Diabetic Medicine 22(Suppl 2): A54
Rossing P (2005) The changing epidemiology of diabetic microangiopathy in type 1 diabetes. Diabetologia 48(8): 1439–44
Soedamah-Muthu SS, Fuller JH, Mulnier HE et al (2006) All-cause mortality rates in patients with type 1 diabetes mellitus compared with a non-diabetic population from the UK general practice research database, 1992-1999. Diabetologia 49(4): 660–6

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