American Diabetes Association

ACCORD and VADT redux

Mathew Riddle, Denise Bonds, and William Duckworth discuss findings at Tuesday's press briefing

Last year's results from two major studies, ACCORD (Action to Control Cardiovascular Risk in Diabetes) and VADT (the VA Diabetes Trial), raised concerns about whether intensive glucose control leading to low A1C and possibly more episodes of hypoglycemia could have negative health effects in some patients. 

At a symposium Tuesday, further analysis of both studies was presented, providing answers to some questions but leaving many still unanswered.

The trials are difficult to compare because of differences in their design and study populations, but the findings suggest that having a low A1C doesn't in itself increase heart risk for most patients. The exception is that patients who don't begin intensive control until they've had diabetes for more than 20 years face increased risk of heart attack and stroke when they do intensify control. 

How Low Can You Go?

In ACCORD's intensive treatment arm, where the A1C target was 6% or less, there was a 20% higher risk of death compared to those in the standard treatment arm, with an A1C target of 7% to 7.9% - but low A1C did not account for it, said Dr. Matthew C. Riddle, professor of medicine at Oregon Health Science University, and a member of ACCORD's Glycemia Management Group. 

In fact, he said, the analysis found that lower A1C actually had a beneficial effect - "the lower the A1C, the lower the risk of death and the higher the A1C, the higher the risk of death.'' 

 

The observation of higher death rates prompted a halt to the intensive glycemic control arm in ACCORD about a year and a half ahead of schedule. The trial, which includes studies of blood pressure and lipid control, has continued and wraps up June 30.

Researchers are continuing to investigate possible explanations for the increased mortality in the tight-control arm of the study. Hypoglycemia, a severe drop in blood glucose level, has been the focus of concern. 

 

An analysis by Dr. Denise Bonds, an ACCORD investigator and now a medical officer for ACCORD at the National Heart, Lung, and Blood Institute, found of the 451 deaths that occurred in both arms of the study combined, 7% had had at least one episode of hypoglycemia severe enough to require medical help. But of the deaths, in only one case was severe hypoglycemia confirmed to have played a role.

Women, African Americans, those with a long duration of diabetes and those who were already on insulin at the start of the study were most likely to have hypoglycemic episodes severe enough to require medical help. 

In those who did have such severe episodes, Dr. Bonds said,"over 50% of events were associated with either missing a meal, eating less than normal or miscalculating carbohydrate intake,'' but it isn't clear if the same could be said for patients who didn't experience hypoglycemia.

Severe hypoglycemia was associated with a higher risk of death overall, she said, but the risk was lower in the intensively controlled group, possibly because those patients had more frequent, though milder, episodes of hypoglycemia, and became more attuned to the symptoms and able to take preventive action. 

Get an Early Start

 

The VADT, analysis revealed that patients who received intensive control of type 2 diabetes in the first 15 years after their diagnosis had lower risk of fatal or non-fatal heart attacks and stroke, but when intensive control doesn't begin until 16-20 years after diagnosis, there was no heart benefit.  

A subanalysis of data from the trial, which involved 1,791 veterans with type 2 diabetes, showed that waiting 20 years after diagnosis to begin intensive glucose control actually increased the risk of heart attack and stroke in the population studied, said Dr. William C. Duckworth, director of Diabetes Research at the Carl T. Hayden VA Medical Center in Phoenix, and co-chair of the VADT.

Key in reducing death risk in the study was an increased level of HDL cholesterol (the "good cholesterol''), Dr. Duckworth said. Exercise and certain medications can boost HDL levels.

 For every 10 mg increase in HDL above the individual's baseline, there was:

• an 80% decrease in risk of fatal or non-fatal heart attack or stroke
• a 50% drop in risk of of a first heart attack or stroke 
• a 55% drop in risk of death from any cause 

Hypoglycemia was found to increase heart risks in VADT participants receiving intensive treatment, researchers found. 

The trial results reinforce the importance of treatment plans tailored to each patient, the scientists agreed. "Type 2 diabetes is extremely heterogeneous,'' Dr. Duckworth said, "so as you treat different groups within the population, you may get different results.''

Treatment of diabetes may be moving away from a single A1C goal of 7% to "different targets for different people,'' Dr. Riddle said. When it comes to heart risks, he said, "we have hints that people with shorter diabetes duration may be a lower risk and that people with higher A1Cs are at higher risk.''

  

 

Competition on Incretins Increases

It all started with gila monster spit. Scientists noticed that the desert creatures eat only a couple of times and year, and they do just fine -- their bodies could handle a huge meal, digest it, and have a normal metabolism before, during, and after. Why was that, they wondered.

They isolated a compound from the saliva of the gila monster which is similar to a hormone made in the human gut that has the wondrous power to promote insulin production only in response to high glucose levels. This hormone, in a class called incretins, is known as GLP-1.  GLP-1 slows digestion and gives the brain the sense of fullness, so it also promotes weight loss.

 

GLP-1 Degraded by DPP-4

Unfortunately, GLP-1 is useless as a drug in humans because it's broken down in a matter of minutes by an enzyme called DPP-4.  To get around that, researchers set out to find ways to capitalize on the insulin-promoting action of GLP-1 and to circumvent the action of DPP-4.

 

A Tale of Two Classes

The result: Two classes of incretin drugs - GLP-1 agonists (GLP-like compounds that resist breakdown by enzymes) such as Byetta, which is injected twice daily; and DPP-4 inhibitors, such as Januvia, which is a pill. The drugs have some advantages over other anti-diabetes medications in that they don't promote weight gain (the GLP-1 agonists actually tend to encourage weight loss) and they reduce the chance of dangerous drops in blood glucose levels known as hypoglycemia.

Other drugs in these classes are in development, and as scientists become more familiar with them, new uses are being explored, said researchers at a symposium during the American Diabetes Association's 69th Scientific Sessions.

Dr. John Buse of the University of North Carolina summarized the latest developments in GLP-1 agonists:

 

• Byetta:  A once-a-week formulation of the Eli Lilly and Co. drug is under FDA review.  Byetta LAR studies presented here show that glucose control and weight loss were sustained over two years, and that improvements were seen in blood pressure and lipids as well.

• Liraglutide:  Under FDA review.  Data presented Monday and published online in The Lancet show in a head-to-head study comparing Novo Nordisk's liraglutide (taken once daily) to the current formulation of Byetta (which is taken twice daily) that liraglutide produced lower glucose levels with less nausea, slightly more weight loss and better control of cholesterol and blood pressure.  In another report, liraglutide showed reductions in weight and blood glucose levels persisting over two years.

• Roche's taspoglutide and GlaxoSmithKline's abiglutide are both in phase 3 clinical trials.

The Future of GLP-1 Agonists

Dr. Rodolfo Alejandro, director of the clinical islet transplant program at the University of Miami, said researchers are exploring another potential use for GLP-1 agonists:  preserving or even increasing the number of insulin-producing islet cells in the pancreas.

 

In animal studies, exenatide caused an increase of insulin-producing cells, he said, so it's possible the drug could be helpful in patients who undergo islet transplantation.  For many of these patients who gain insulin independence post-transplant, the effect diminishes over time.

 

"With exenatide," he said, "maybe we can deal with chronic impairment of islet function."  He said that question and others will be investigated in future studies.

Dr. Kahn's Excellent ADA Adventures

After nearly a quarter century at the American Diabetes Association, Dr. Richard Kahn, chief scientific and medical officer, is retiring at the end of June. 

During the more than ten years I covered diabetes for USA Today, I regularly called on Dr. Kahn -- to pick his great brain, to seek his opinion on the latest diabetes news and to ask him to put new research into perspective.  Always, he spoke his mind and I knew that with Dr. Kahn, what he said was exactly what he believed. That quality of forthright outspokenness has gotten him into trouble, but it has earned the respect and admiration of many, me included. So, here, in what may be our last on-the-record interview, Dr. Kahn reminisced about his time at ADA and revealed his plans for the future. As always, he spoke his mind and was very entertaining:

Q. Are you really retiring or just switching careers?

Kahn:  I don't have any work plans at all. Oh, I wouldn't mind bringing in some lunch money, consulting maybe. That would fuel my collecting of things. I'm a sick pathological collector and everything I collect comes with books, magazines, conventions. I've not been able to get to them.

Q. What do you collect?

Kahn: Turned wood. Glass. Oriental rugs. Lithographs from the '30s and '40s. Bonsai trees. Watches. Pens. Old maps of America.

Q. Any other plans in mind?

Kahn: In the Washington area there are more than a dozen Smithsonian museums. I would like to have one day a week as "museum day'' and attend all the lectures. ..(Also)  I was a cook in the Army and I want to go back to cooking dinner five nights a week, a different recipe each time. ..And have time to attend my kids' sporting events and concerts... And I've gotten interested in handyman-ing and a neighbor is going to teach me woodworking.

Q. Is there more?

Kahn:  I'm really interested in writing a book. 

Q. So, no rocking chair for you. Let's talk about the ADA. What were the Scientific Sessions like when you started to work there?

Kahn: I didn't think it was very impressive, though I think people who went to the meeting thought it was. There were four symposia as opposed to 35 (now); 15 invited speakers as opposed to 180; 2,000 attendees versus 20,000. It was just a fraction of what we have now.

Q. And it was you who helped develop and expand the Scientific Sessions, isn't that right?

Kahn: I think I did. I thought of ideas and the committees agreed, but we couldn't have done it without a lot of volunteers, they were essential. 

Q. How did the Scientific Sessions evolve over the years?

Kahn: We tried some things that had never been done, and some of them stuck.

Q. Like what?

Kahn: We had discussions sessions - now lots of meetings have them, where you have controversies and people debate. We had receptions for posters where people were encouraged to have social (time). We have tracks, where people can stay with a particular topic through the whole meeting. All the different kinds of symposia and topics -- we bring in people from outside the field of diabetes (to show) how their work could apply to ours. 

Q. Did you have something to do with ADA's practice of recommending clinical guidelines?

Kahn: I started them in 1988. We got a lot of hate mail. People said we shouldn't be doing this and Richard should be fired. We started the concept of performance measures. We started consensus conferences, clinical conferences ...

Q. Who was setting guidelines before ADA?

Kahn: No one. I said if we're going to be the authoritative voice and lead the world in diabetes, why don't we offer advice on how you define quality care? What would ideal care be like? It translates into ADA standards for the medical care of people with diabetes. But there was a huge controversy. It was initially rejected by the leadership of the organization. We just came back the next year and said this is a role for ADA. This determination has contributed to progress made by the ADA, so (now) ADA has set the standard and is the leader in diabetes in the world.

Q. Were there other roadblocks along the way?

Kahn:  Almost every single new thing we tried was vetoed by some authoritative body in ADA saying we shouldn't do that. ... That carries over to today. But it's just the nature of mankind.  Change can be difficult.  You try to institute something new and there are always people opposed to it - and they're more vehement than the people who support it. It's very challenging and people know that I love a challenge.

Q. Would your road have been smoother if you hadn't tried to plow new ground all the time?

Kahn: It's always been in my nature to love to do things that are new. I just like it, I don't think of it consciously. I'm not good at maintenance. 

 

.......

 

At the awards ceremony today, Dr. Kahn was presented with the Charles H. Best Medal for Distinguished Service.

 

What you don't know (about diabetes) can hurt you

Knowledge of diabetes and its risk factors is improving, a new survey suggests, but significant gaps in understanding persist. 

Dr. Judith Fradkin, who leads the diabetes program at the National Institute for Diabetes and Digestive and Kidney Diseases (NIDDK), presented results of a national survey conducted for the National Diabetes Education Program that she says may help improve patient education. Examples:

• 63% of those surveyed who do not have diabetes but believe they are at risk for it list family history as the reason for their concern. Among African Americans, 83% cited family history as their biggest risk, and among Hispanics, 70% cited family history.
• Only 22% of those surveyed cited their own overweight or obesity as a risk factor for diabetes, but 68% said weight is the greatest risk in other people.   
• Less appreciated risks included age (23%); race or ethnicity (16%) and too much salt in the diet (14%)
• Asked to name the most serious health problem caused by diabetes, 54% said blindness, 34% said cardiovascular disease. (Yet heart disease and stroke are the leading cause of death in people with diabetes.)
• Among the 19% of respondents who said they have diabetes, only 2/3 had an A1C test in the last year and of those, fewer than half knew what it was.
• Some messages are getting across - 80% of people said losing weight will improve blood glucose. But only about half of those surveyed had ever heard of prediabetes.  

The survey results will help guide future communication about diabetes, Dr. Fradkin said.  "Based on this information, we are changing NDEP risk messages, for instances, to emphasize family history - to reach people with issues they recognize."

 

 

Does reporting eAG clarify - or confuse?

A debate is raging here at the ADA's 69th Annual Scientific Sessions over whether doctors who order A1C tests for their patients should receive the results in two forms - the standard A1C reading, which is given as a percentage, and another number that is in the same units people see when they use their glucose meters each day to test their blood. 

The idea to present patients with their estimated average glucose number (eAG) is that it will be more familiar and understandable, because it will look like the numbers they see in their glucose meters.

In speaking in favor of the eAG, Dr. David Nathan of Massachusetts General Hospital in Boston showed data from the ADAG study (an international study that compared A1C readings with blood glucose measurements) that indicates eAG numbers correlate closely with hemoglobin A1C. For instance, an A1C reading of 7%, which is the goal for many people with diabetes, is the equivalent of an eAG of 154 mg/dl. A person without diabetes might have an A1C of 5%, which is the equivalent of 97 mg/dl. 

"We think of obesity as a health risk and we talk about BMI versus weight,'' Dr. Nathan said. "What if you were told to keep your weight down, but then were told that you needed, over a long period, to get your BMI down -  and what if you weren’t told how to calculate that. What if (patients) were told to exercise 30 minutes a day, and at their yearly checkup were told that their energy expenditure in ergs was inadequate.''

That would be confusing. Thus, Dr. Nathan recommends use of eAG as the basis for measuring long-term glucose control, in the same units as a patients' familiar glucose meter readings. 

Both the ADA and the American Association for Clinical Chemistry, sponsors of Sunday's debate, recommend that labs using A1C tests also report eAG, but in other countries, there is disagreement. The UK has decided there's not enough evidence to recommend it, and Germany restricts what labs can report, so they may not be permitted to report the eAG, which they aren't actually measuring - it's an estimated equivalent to the A1C number. 

Speaking against eAG reporting from the perspective of a clinician was Dr. Zachary T. Bloomgarden of Mount Sinai School of Medicine in New York City. He challenged whether eAG is an accurate equivalent of A1C, noting that the study on which the equivalencies were based did not account for A1C differences based on race, age and other variables. 

Further, he said, when patients bring their glucose meters to their medical appointments, the doctor may download dozens of daily readings whose average may differ from the eAG reported by the lab. For instance, the patient's A1C may be 7.5% and the average glucose reading on the meter might be 142, particularly if the patient is used to testing only before meals. But the eAG reported by the lab would be 169. The discrepancy could confuse patients, Bloomgarden said.

He also cited analyses that he said called into question the reliability of A1C in all populations. "There are weaknesses (in A1C reliability) and these considerations call into question reliance on A1C as a goal and its use in diagnosis of diabetes in divergent populations of varying age and ethnicity,'' he said. 

Speaking from the perspective of the medical lab, David Sacks of Brigham and Women's Hospital in Boston pointed out that the ADAG study showed a linear correlation between A1C and eAG - and raised the question of how many patients really know what a hemoglobin A1C test is all about. 

He said the ADAG study showed a "linear correlation between A1C and average blood glucose concentration,'' and said many US labs already report both A1C and eAG - though they don't all use the same calculations. 

Sacks said there are good reasons to report eAG: many health-care providers find it useful; the ADA believes it will improve communication between doctor and patient, and "the most important reason,'' he said, is that "the most enthusiastic supporters are diabetes educators.''

But Dr. Eric S. Kilpatrick of the Department of Clinical Biochemistry at the Hull Royal Infirmary in the UK argued against eAG, saying that the measurements developed in the ADAG study are not precise and could produce numbers that are way off the mark.

"Experienced diabetologists are already aware and take into account imperfections with the A1C,'' he said. "By introducing the eAG, this task is being offloaded to patients. A move to eAG could introduce a whole new layer of confusion for patients and less-experienced health care staff.''

Dr. Nathan said variability between meter readings and lab-reported eAG can easily be clarified. "If they're not correlating, you say maybe your glucose levels are higher when you're not measuring,'' he said. The bottom line is that A1C tests have been shown to be useful.

The goal of reducing A1C levels, he said, "is improving the health of diabetics around the world, let's face it.''

Heart Surgery vs. Drugs - Is There a Difference?

Trevor Orchard, MD and  Susan McLaughlin, RD, CDE, ADA's President of Health Care & Education, discuss new findings on BARI 2D

In a major study that looked at treatment of patients who have both diabetes and coronary artery disease, scientists found no difference in rates of death or of heart attack and stroke between those who received early revascularization - either bypass surgery or angioplasty - and those who underwent intensive drug therapy. 

But, a subgroup of patients who got bypass surgery had fewer heart attacks and strokes when compared to those on drugs alone, said Dr. Trevor Orchard of the University of Pittsburgh Graduate School of Public Health, who on Sunday described results of the five-year Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes - the BARI 2D study. 

 

Most Striking

Cardiologist Dr. Robert L. Frye of the Mayo Clinic, Rochester, said from the perspective of cardiology, the "most striking finding is identification of a high-risk group of patients who were selected for coronary bypass...who benefited from prompt coronary bypass.''

Bypass surgery has never been shown before to reduce heart attacks in patients with mild symptoms and stable disease, he said.

 

"That emphasizes the importance of continuing a long-time effort'' - enhanced by new imaging technologies - "to identify patients who would benefit from revascularization.''

 

The study won't change clinical practice, the doctors said, but it does provide guidance on how to best use medical therapies and who will benefit most. 

 

The Specifics

The study involved 2,368 patients and was designed to compare prompt revascularization with intensive medical therapy. Patients in the study were those who had evidence of coronary artery disease and type 2 diabetes. They then were randomly assigned to whichever revascularization approach was recommended by a cardiologist, or to intensive medical therapy. 

 

Those in the medical therapy groups were assigned to get either insulin-sensitizing drugs or insulin-providing drugs.

 

Both drug types resulted in similar outcomes in terms of deaths or heart attacks, but, said Orchard, "results showed that insulin-sensitizing drugs (Avandia) which have been of concern to some degree in the past, are not harmful,'' and in fact may have advantages in reducing weight gain and hypoglycemia.

 

Additionally, scientists noted that the greatest benefits of early bypass surgery were seen in patients who also were taking insulin-sensitizing drugs.

 

Take Home Message

Dr. Orchard said that insulin-sensitizing drugs are safe and medical intervention can be successful in treating cardiovascular disease in patients with "this deadly duo of diabetes and heart disease.''

 

Dr. Frye added that the study emphasizes the importance of patients sharing their symptoms with their doctors. "I try to make sure patients tell us if they're beginning to have symptoms of unusual breathlessness or chest discomfort.''

 

In fact, he said 18% of patients in BARI 2D had no symptoms when they entered the study. "Patients with type 2 diabetes may not experience the typical chest pain we describe as angina.'' 

Diabetes Trailblazer Wins Banting Award

The scientist who showed the world that type 1 diabetes is an autoimmune disease, and who continues to push the boundaries of scientific inquiry, spoke hopefully about the future of diabetes research and encouraged his audience to "pioneer the prevention of type 1 diabetes.''

Dr. George S. Eisenbarth is Executive Director of the Barbara Davis Center for Childhood Diabetes and winner of the American Diabetes Association's prestigious Banting Medal for Outstanding Scientific Achievement.

 

During today's lecture to a packed audience, he said that it is now known that type 1 diabetes, the form of the disease that results from immune destruction of insulin-producing cells in the pancreas, "is hard-wired in the genome.'' 

 

As scientists hone in on genetic and other physiologic causes, he said, it has become possible to predict who is at highest risk, and ultimately, he said, "prevention will be achievable.''

 

But, he noted, there must be more than genetics at work because "we know that type 1 diabetes incidence is doubling every 20 years in Western societies, especially for youngest-onset.''

 

Squeaky Clean

That isn't happening in developing countries, and there are various theories to explain it, including the "hygiene theory.'' This theory suggests that as infectious diseases decline because of hyper-cleanliness, our immune systems are not stimulated as much as they were in earlier generations, leading to an increase in autoimmune diseases. It's also possible there is a virus that trips the genetic predisposition, and if it could be identified might be averted with antiviral medication.

 

Whatever the environmental trigger, he said, it is likely "ubiquitous, not rare.'' 

 

Nancy Drew to the Rescue?

Diabetes risk is "determined by one's genotype,'' he said, but while research is teasing out some of the mysteries, "we're not yet at the tipping point. The list of positive (studies) in various stages of replication is small - but increasing.''

 

Among hopeful investigations are:

• the use of oral insulin
• efforts to develop a vaccine
• a study (reported at this meeting Saturday) that found a rheumatoid arthritis drug improved symptoms

What we know so far, Eisenbarth said, is that we can predict type 1 diabetes, insulin may be an autoantigen - a normal body chemical that stimulates an immune response - and drugs that suppress immune response can dramatically delay, but not halt, diabetes.

 

However, "a lot we know may be wrong,'' he said.

 

Trailblazer in Training

In announcing him as the Banting Medal winner, the ADA praised Eisenbarth, who is Professor of Pediatrics, Medicine and Immunology at the University of Colorado Denver School of Medicine, noting that "the major tenets developed as a consequence of his discoveries guide basic research, clinical diagnosis and disease therapy to this day.'' 

 

A native of Brooklyn, Eisenbarth grew up in a working class neighborhood. His mother, who worked in an electronics factory, "always assumed I would be a doctor,'' he said, and "would read to me from a science encyclopedia'' as they rowed on a lake in the Catskills.

 

His father, who had a sixth-grade education, worked as a cook at the Natural History Museum in New York, so young George got to spend time there. At the urging of a high school teacher, he applied for and won a Pulitzer Scholarship to Columbia, and was on his way.  

In his lecture Sunday, he sounded an optimistic note for the future. Thanks to new tools and technologies, scientists can "build on current successful trials and... with luck, permanently arrest'' the destruction of insulin-producing cells -- stopping type 1 in its tracks. 

The Gene Effect

Tight control of blood glucose in type 1 diabetes is not entirely a matter of diet, exercise and medications, say researchers who reported Saturday that they've found four genes related to glycemic control in type 1. 

Two of these genes also affect the risk for kidney, eye and cardiovascular complications of diabetes and one influences the rate of hypoglycemia, or low blood glucose, said lead author Andrew D. Paterson, Senior Scientist in the Program for Genetics and Genome Biology at the Hospital for Sick Children in Toronto.

Paterson and colleagues sifted through data from the Diabetes Control and Complications Trial (DCCT), an NIH-sponsored study begun 25 years ago that compared intensive control of blood glucose to conventional control in 1,441 people with type 1.

 

The intensive arm of the study involved:

• at least three insulin injections a day or use of an insulin pump
• at least four glucose checks a day, aimed at bringing A1C levels to 6% or less.

The conventional arm required:

• only two insulin injections
• blood tests which resulted in A1C levels of 9% or more. 

Sixteen Years Ago
Results of the DCCT reported in 1993 showed intensive control drastically reduced the eye, nerve and kidney damage that are often long-term complications of diabetes.  A follow-up showed that intensive control also reduced the risk of heart disease.

 

Today's News

In the genetic study reported today, researchers conducted genome-wide studies, comparing gene positions of interest in each of the two study arms. 

Dr. Paterson said in a press release that the information gives insight into the mechanisms influencing glycemic control in type 1, but "it is important to remember that the overall influence of genes is small and may vary from person to person and, perhaps, in response to behavior.''

That means people are still on the hook when it comes to their actions, he said.

 

"This finding does not give people with diabetes the freedom to slack off on their careful nutrition, exercise and medication regimens," he said, "because behavior clearly plays the major role in glycemic control."

 

Dr. Paterson also said the findings may ultimately help identify people at risk for poor glucose control and complications of diabetes, so steps could be taken to avert those problems.

 

In the meantime, the study may inform design and analysis of other genetic studies and point to new research directions. 

Is the Child with Diabetes Safe at School?

Christian Stokes, 18, the ADA's National Youth Advocate, is here at the meeting and his first blog post reports on a symposium Saturday morning that focused on keeping students with diabetes safe at school. Check out his blog to read all about it. 

Law Abiding Schools?

Sadly, even though they're required by law to provide services to all students under the Americans with Disabilities Act, many schools lack the trained staff they need to fulfill that mandate.

A poster presented Saturday by researchers at Rainbow Babies & Children's Hospital and Case Western Reserve University underscores that. They sent out questionnaires to 99 families with children in grades K to 12 with type 1 diabetes.  The questionnaires also were sent to the head school nurses in districts where those youngsters went to school.

The parents reported that schools don't consistently meet the American Diabetes Association guidelines for the safety and management of children with diabetes.

Most schools report meeting most guidelines. BUT 90% don't meet all of them. And there are big gaps in the partnership between family and school that should be improved to ensure the best care for children with diabetes in school. 

One Teen's Crusade to Make Schools Safe

As the National Youth Advocate, Christian will do a lot of traveling this year, drumming up support from young people, adults and elected officials to join together in the fight against diabetes. 

He would like to see greater knowledge and understanding of diabetes, especially among teachers and counselors of children.

Christian, who was diagnosed with diabetes as a baby, recalls an incident some years ago at camp. He needed to test his blood glucose, and the counselor said, "Would you not do that here? We don't want a freak show." 

Math Class - Dangerous to Your Health?

In an ideal world, teachers would not forbid students with diabetes from eating what and when they need to, or testing their blood or giving themselves injections.

"In a perfect world, you could test wherever you want and all teachers would know what diabetes is and how to help the student,'' he says.

Many schools require children to go the nurse's office to test.  "That's dangerous,'' he says. Negotiating stairs and school corridors in a state of hypoglycemia could be disastrous. "If you're low you need to eat something right away.''

Besides that, "you're missing a third of the school day because you have to keep running to the nurse, and sometimes you have to wait for the nurse to come in.'

Christian's mother Heidi says to avoid problems like that, Christian attends a small private school, where the staff know and understand him. 

"I've been lucky,'' he says. "I've only had a few problems in school, like the time my blood glucose was high and the teacher wouldn't let me get a drink of water.''

He puts the small moments of discomfort he has experienced in perspective: "I've met kids who haven't been allowed on field trips or were excluded from class because they have diabetes.'' 

With that, he shakes his head - and heads off to another symposium. 

Don't Beat Yourself Up

Ask anyone with diabetes - sticking to the daily routine of diet, medication, and monitoring of blood glucose levels is no walk in the park. And when you try and try but still don't meet the goals you and your doctor have set, it can be, well, a bummer. 

Researchers at the Joslin Diabetes Center in Boston report in a poster on Saturday that they interviewed and evaluated patients with type 2 diabetes to assess their perceptions, attitudes, and behaviors that support or hinder their treatment.

 

Among patients who are not meeting treatment goals, three themes emerged:

 

1. Perceived personal failure. Patients say they failed to follow doctors' orders, and that's why they didn't meet their goals.
2. Self-blame. They blame themselves for "not doing what they should be doing'' to take care of themselves. If results were unexpected and poor, patients tended to turn anger and frustration inward
3. Emotional vulnerability. Patients feel defeated and depressed because they're not meeting their treatment goals. 

The researchers say it's important for doctors to recognize signs of this kind of emotional strain in their patients who are struggling. People with diabetes are at higher risk for depression compared to the general population, they note, so paying attention to the psychological needs of patients can pay off in better mental and physical health.