Who Benefits From Intensive Therapy in Type 1 Diabetes?
A fresh perspective, more questions, and hope
- Barbara J. Anderson, PHD
- From the Baylor College of Medicine, Texas Children’s Hospital, Children’s Nutrition Research, Houston, Texas
- Address correspondence to Barbara J. Anderson, PhD, Baylor College of Medicine, Texas Children’s Hospital, Children’s Nutrition Research, 1100 Bates St., Room 2054, Houston, TX 77030. E-mail: bja{at}bcm.tmc.edu.
Our assumptions about what kinds of patients benefit most from intensive therapy (IT) are rarely questioned. Thanks to the empirical evidence provided by Wysocki et al. (1) in this issue of Diabetes Care, we now have a fresh perspective on the critical question of who benefits from IT. In the landmark study that established the benefits of IT for people with type 1 diabetes, the Diabetes Control and Complications Trial (DCCT) employed strict eligibility criteria and screened out patients who were assessed as too unstable or unmotivated to follow through on the rigorous demands of IT. Each DCCT participant had to complete a series of demanding behavioral tasks during the run-in period before randomization. Thus, the DCCT study population was a “young, generally healthy, and highly motivated” sample (2) that was also steadily employed and lived in a stable home environment. The assumption that IT was best suited for the highly adherent and informed patient, which guided the DCCT screening procedure and subsequent decisions about who would adhere to and benefit from it, has become dogma (2).
This legacy is turned upside down by the empirical data of Wysocki et al. Their data suggest that patients/parents with the lowest levels of diabetes knowledge and adherence had the greatest glycemic benefits from IT. As one part of a larger pediatric randomized trial of IT versus usual care (UC), the authors sought to identify and objectively characterize the subgroup of youth (and their families) that experienced the most significant glycemic benefits from participation in IT. As in the DCCT, very different levels of support and services were available to families in the IT condition as compared with UC. Families randomized to UC received quarterly clinical visits with the nurse and physician, one annual clinical visit with a dietitian and a …
