Editor's Note
Re-engineering Diabetes Care
I’ve often thought engineers make the best diabetes patients. They are precise. They like to measure and record things. And they usually take instruction well. I have patients who arrive for their follow-up visits with pages of blood sugars laid out in Excel spreadsheets, frequently with three-color graphs that show trends and even statistical significance calculations. With a precision bordering on the compulsive, they watch their diabetes and, as a result, they usually do well.
Diabetes needs watching. Few chronic diseases demand such hour-to-hour tending. Since studies in the early 1970s confirmed that tight control resulted in less end-organ damage, doctors have pushed their patients for fastidious blood sugar control. In the test-your-urine-sugar, nonglycosylated hemoglobin era, diabetes treatment was part guesswork, part art, with a touch of science. As a result, even the most obsessive patients could achieve only a modicum of control.
Now, with pocket glucometers, patients on oral medications can do regular blood sugar checks to catch any trend, low or high. Insulin-dependent patients can adjust their insulin doses three or four times a day. Constant blood sugar monitors the size of quarters with probes inserted subcutaneously can give doctors and patients a 24-hour snapshot of blood sugar values with enough data and graphs to keep any engineer happy.
But both patient and doctor would rather not do all this fussing. Ideally, a person with diabetes would be just like a person without the disease, not having to think about his pancreas or blood sugar during the course of a day. The technological answer to this is the insulin pump, delivering jolts of insulin with increasingly sophisticated algorithms to keep blood sugar as close to physiologic as possible. Yet it still requires the patient to measure blood sugar and adjust the pump. A totally hands-off feedback system of blood sugar driving insulin delivery hasn’t been developed yet.
Another solution is to replace the pancreas with one that works. Yet even though pancreas transplants have taken giant strides forward since the first successful one in 1966, only a small fraction of people with diabetes still qualify for consideration and transplanted patients trade insulin hassles for immunosuppressive troubles.
The ultimate answer to the demands of diabetes is cure. Centuries after the first patients tasted their sugary urine and 90 years after insulin was isolated and used on patients, it somehow seems that we would be closer to finding the cure for a disease that afflicts millions. As Jeanne Mettner’s article indicates, it’s not for lack of trying. As with so many diseases, initial searches for a single etiology that can be zapped by a magic bullet have been stymied by the realization that diabetes is many diseases, and one cause will not likely be found and one cure will not likely suffice.
So, for the time being, finger sticking and medication tweaking are with us. And we’ll have to teach patients with diabetes to be engineers.
Charles R. Meyer, M.D., editor in chief, can be reached at cmeyer1@fairview.org