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© 2002 by the American Diabetes Association, Inc.
Letters: Comments and Responses |
Editor’s Comment: "It Ain’t Necessarily So"
From the Clinical Trials Unit, Charles R. Drew University, Los Angeles, California
As much as we may wish to believe that diabetes education per se leads to improved long-term glycemic outcomes, the evidence is not particularly strong. The review by Norris et al. (1), to which the letter by Sone et al. (3), above, is addressed, and an earlier one by Clement (2) do not support this contention. Likewise, neither does the accompanying letter by Sone et al. (3). They contend that the 0.16% difference in HbA1c levels after 3 years between an intervention group receiving diabetes self-management education and a control group receiving regular conventional care in the Japanese Complications Study would be "clinically meaningful because each 1% reduction in HbA1c levels over 10 years has been shown to be associated with a 37% reduction in the risk of microvascular complications in the U.K. Prospective Diabetes Study (UKPDS) (4)." Unfortunately for the hypothesis, it is an average reduction of 1% in HbA1c levels per year over 10 years—not a cumulative decrease over 10 years—that leads to this favorable outcome.
For those of you who remember trying to prove mathematical theorems, the concepts of necessary and sufficient are germane, in my view, to the situation concerning diabetes education and glycemic outcomes. Certain conditions are necessary to prove theorems, but they won’t do it by themselves. On the other hand, for some theorems, if a specific condition is met, it is sufficient to prove that theorem all by itself. I think of diabetes education as a necessary condition, but without an appropriate management component, it is not sufficient. On the other hand, without appropriate education, a management piece is usually not all that effective. Therefore, in this analogy, the difficulty of showing the effectiveness of diabetes self-management education is that patients often return to medical environments in which appropriate management is lacking.
Footnotes
Address correspondence to Mayer B. Davidson, MD, Director, Clinical Trials Unit, Charles R. Drew University, 1731 East 120th St., Los Angeles, CA 90059. E-mail: madavids{at}cdrewu.edu.
References
- Norris SL, Lau J. Smith SJ, Schmid CH, Engelgau MM: Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care 25:1159–1171, 2002
[Abstract/Free Full Text]
- Clement S: Diabetes self-management. Diabetes Care 18:1204–1214, 1995[Medline]
- Sone H, Ito H, Yamashita H, Ishibashi S, Katayama S, Abe R, Ohashi Y, Akanuma Y, Yamada N, the Japan Diabetes Complication Study Group: The long-term effects of self-management education for patients with type 2 diabetes on glycemic control (Letter). Diabetes Care 25:2115, 2002
[Free Full Text]
- Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR, on behalf of the UK Prospective Diabetes Study Group: Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 321:405–412, 2000
[Abstract/Free Full Text]
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