How do you top the GlucoMON’s ease of use and effectiveness in changing behavior? With such a successful track record it’s hard to come up with the next great thing… and I think my team has done it again. Stay tuned for HEALTHIMO (launching January 1, 2010). Anyone want to take a guess?

One reason we need a real “cure” for diabetes is that most “free range” diabetic patients can’t manage their diabetes consistently well enough for several legitimate reasons that modern medicine can’t really change.

The landmark Diabetes Control and Complications Trial (DCCT) proved the virtues of tight blood sugar control. Yet it took a decade to conduct (1983-93) and required near superhuman effort to keep 1,440 people with type 1 diabetes in consistent diabetes control over that entire time.

But the real story behind the DCCT is what still haunts us today. It’s our inability to apply its conclusions and recommendations into the lives of millions of people struggling with diabetes across the globe.

Several things had to happen in order for DCCT to happen, which are the real reasons we have never been able to duplicate its results on a large scale in most type 1 diabetics. It’s been said that only 5% of diabetic patients can even now possibly attain and sustain DCCT-like levels of blood sugar control.

Patients enrolled in the DCCT were between 13 and 39 years of age at the start of the study. That meant that applying the results to patients outside those ages would not be scientifically defensible or maybe even wrong. Yet, I see that being done now by pretty much everyone in the profession.

Next, (and this is DCCT’s real dirty little secret) all study patients were prescreened for any pre-existing mental health or social conditions that would keep them from being able to maintain good control of their diabetes. In other words, potentially non-adherent patients were systematically excluded from the study. If I had the ability to pick and choose “winners” like that in the real world, my clinical outcomes would look fantastic too. But the world is full of poorly motivated, mentally/socially challenged and frankly mentally ill adults and children who just happen to have diabetes too. Where do they fit in this model of diabetes health care delivery? They don’t.

Everyone in the DCCT was provided diabetes supplies at no direct cost to them. This included insulin, syringes, insulin pump supplies, meters and test strips, etc… everything but food. When we consider the high costs of daily diabetes care now, this becomes a significant financial barrier to good outcomes. In the current discussion about health care reform resulting from tens of millions of uninsured Americans , diabetes ranks high on the list of financially crippling diseases that often get neglected simply because there is no way to pay for the proper care and equipment, or the diabetes self care education needed to manage it each day.

Finally, (and this also speaks to resource allocation) consider that DCCT patients in the treatment group (aimed at keeping A1c low and keeping it there) all got monthly visits to the diabetes doctor and weekly calls from the diabetes nurse to make constant adjustments in their daily management aimed at keeping blood sugar levels in tight control. Communication was almost always by phone or fax. In that regard, DCCT was the first study to really prove the value of telemedicine and diabetes care outcomes on such a grand scale. And this was accomplished well before cell phones, text messaging, computers and the Internet began to permeate our everyday lives.

Ultimately, the DCCT represents a search for a “Holy Grail”: perfecting blood sugar control and lowering the long term complications of diabetes. But like the legendary Holy Grail, this one still remains undiscovered and may never have really existed in the first place. In the end, the power to succeed over diabetes lies in every one of us. DCCT proved it could be drawn out in a select few. But as our natural riches may be buried at different depths within the ground below, how deep do you and others have to drill down in order to unleash your power within?

This is a topic I’ve been thinking about for a while but haven’t come up with the right angle or the interesting thoughts beyond the obvious until now I suppose. However, you the reader can be the judge of that.

Now it’s about the Medingo pump - a so-called ‘upgrade’ to the ‘revolutionary’ Omnipod by Insulet. Revolutionary in that it eliminates the tube (while simultaneously introducing several of its own technical issues and glitches). Does it make life with diabetes easier vs a pump with tubing or does it give the user better control over their blood sugars? Not so much. At least it’s not clear to me that the pump or any device for that matter can do that by itself. What if there was an all in one blood glucose meter that doubled as a cell phone with two way text messaging (they want you to say ooh here)… So what? There are already several of these by the way, including a few different versions created by Diabetech’s engineering team. My engineers would agree that these devices by themselves are a big so what. NONE of them have data to show that they are any better at helping a person to control their diabetes nor do they make life easier for the patient. What about the new iPhone diabetes mania? Again, just a tool… so what. CGM is here. Why such a mixed review by the people who are lucky enough to have this available as a covered benefit by their insurance? What about Health2.0? Again, a collection of discreet tools that ask you to spend more time figuring out how to use it by yourself as a one-off. Where’s the focus on solutions or integrating this tool with that tool… a real recipe for success? That group told me they’re not interested in that yet but maybe some day in the future. Huh?

We’re back to the question of how does all of this technology get used by the patient which determines the result.

I’ve been in this field for 8 years now and I still don’t know of any regimented program for how one would use an insulin pump to get specific outcomes. The analogy would be Dr. Bernstein’s low carb/ no carb diet as a prescriptive guide to do this behavior and get this outcome (a non-diabetic A1c below 6 aka the Under 6 Club). Perhaps this is because of the complexity of matching insulin to carbs and the myriad choices made every hour or two by the patient that makes this unrealistic to have a militaristic prescriptive for living with a pump. But why not attempt something like a diabetes boot camp for controlling blood sugar with the emphasis on the regimen and choices vs. ‘See all these new features’ and use them however you like or don’t or skip boluses or whatever. Rightly or wrongly we’ve come up with a term describing scenarios of patients and their random approaches to how they manage as The Free-Range Patient. We chuckle about this but isn’t this really at the root of why it’s so difficult for a provider to ‘manage’ their patients? The fact is that the only person who manages the patient is the patient himself. Providers should stop using ‘managing patients’ since it is entirely incorrect and perhaps gets in the way of the proper perspective which is more of a coach. Mentor isn’t even appropriate unless of course that level of relationship has truly been established which most often times it has not since that is a rare relationship indeed.

Now here’s something that doesn’t require a new device, which can save lives and give you back more sleepful nights while also helping you to improve blood sugar control. This little trick was implemented under the close supervision of our own Stephen Ponder (pediatric endocrinologist) and a team of medical staff ‘hovering’ over their kids. This revolutionary new technique is being written up by Dr. Ponder as we speak and hopefully we can grab an excerpt of it for publication on this blog soon. This new tool is called… wait for it… extended bolus. The trick is in how this tool is applied however. Very cool and worked wonders at diabetes camp this summer. That’s about all I can say so as not to steal his thunder but stay tuned for this awesome new technique that is sure to give many a real boost to their blood sugar control.

So when the bus comes by again to pick everyone up so that they can ooh and ahh about the next magical device for people with diabetes, you won’t see me getting on. What I will do is give it the sideways look and see if it helps to solve a certain problem or remove a barrier to improved self-care as part of a prescriptive program addressing a very specific lifestyle-demographic. More simply, is it truly useful or not by itself and if not, can we make it useful as part of a prescriptive system/program?