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DCCT 30-Year followup

Discussion in 'Parents of Children with Type 1' started by Darryl, Sep 25, 2013.

  1. Darryl

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    Not sure if anyone posted this already. I saw it in Gary Scheiner's newsletter today.

    http://www.medscape.com/viewarticle/806768

    Since the original study period both groups A1C's have converged at about 8%, but the original intensive control group who kept their A1C's around 7% continues to enjoy far lower incidence of microvascular complications as well as lower risk for cardiovascular disease. The message from this? It seems that tight control in the early years after diagnosis matters a LOT (see "metabolic memory"). Consider this if you have an endo who still clings to the belief that there is a "protective effect" for young children, so A1C's of 8+ are not a problem. Quite the opposite could be true. All the more reason why CGM's and training in intensive control should be prescribed for children.
     
  2. virgo39

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    Thanks, I had not seen this.
     
  3. Sarah Maddie's Mom

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    The whole "metabolic memory" thing is really interesting. I have heard Joe S talk about this, but our endo/CDE has never brought it up. Granted, they have always pushed us to aim for 7 so perhaps they feel it goes without saying.
     
  4. Darryl

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    I think it's not really a "metabolic memory," it's that many of the DCCT participants were children and young adults. Their bodies were still evolving and benefitted from early intensive control. I think that childhood is the most important time of all to maintain good BG control despite the fact that it's hard to do with young children. Fortunately we have technology nowadays to help with that.
     
  5. TheFormerLantusFiend

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    The DCCT participants were age 12 and up, and you had to be able to feel your lows to be enrolled in the study.
    When I read about having to be able to feel lows, I just felt like, oh, the DCCT is not about people like me.

    Also, there seems to be major protective benefit from complications in people diagnosed under 5 years. I think going for A1cs of 8% is a much more defendable position for 4 year olds than 14 year olds.
     
  6. Darryl

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    Is there an article about that?
     
  7. hawkeyegirl

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    I've seen it before too, but my recollection was that it was limited to kidney complications. Let me see if I can find it.

    ETA: Here, look at this.
     
  8. Mish

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    I can't get to the article at all, but I'm wondering if states where the cut off is for benefit/no benefit? Is it necessary to be trying to shoot for non-diabetic a1c's in the 5 range? Or is 6.5 or 7 equally as good?

    Ok, I finally got into the article. So basically it's just saying that those who kept their a1c around 7, in the original intensive group of the original DCCT, carried the benefit for longer. It doesn't really speak to tighter control below that though. Just that tight control (which they're calling an a1c of 7%) early after diagnosis is beneficial later.
     
    Last edited: Sep 26, 2013
  9. Momontherun

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    Thanks for the info. I don't get how an A1c of 8 is great. There is the big picture and where number were before and you don't want bad lows in kids. Providers think I am over zealous wanting CGM and to test frequently but I am responsible for my 12 yo health and I want to prevent complications if possible. He was dx at 11 so I have to take this serious. I would be able to control diabetes many days but I can get it a darn good try till he is on his own.
     
  10. MomofSweetOne

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    The DCCT was done in an era of different insulins when tighter control was much more dangerous than it is now. Insulins that peak during the night, no CGMs, etc. We're fortunate our kids have the benefits they do. My kid is sick this week and not wanting to eat much. I'm so thankful I don't have to force her to eat because of an insulin peak, that we don't have to eat when the insulin peaks, that we have not only blood meters but also a CGM,...and I look forward to the day that this seems like ancient technology in her life.
     
  11. Darryl

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    It will be a long time before anyone knows for sure if the kids whose A1C's are in the 5%-6% range have lower incidence of complications than kids in the 7% range, because that level of control has been possible (safely and consistently) in the general population of children with juvenile diabetes only in the last decade with the introduction of the CGM.

    What we do know is that the human body is designed to work with blood sugar in the 80-90 range fasting (majority of the 24-hour day) and post-prandial BG's peaking briefly in the high 100's 1 hour after a high-carb meal and 140 max 2 hours after a high-carb meal.
     
  12. TheFormerLantusFiend

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    In addition to what Karla cited, I have seen very significantly lower rates of retinopathy, and slightly lower rates of neuropathy, in the studies I've read for people dx'd under 5 years vs older ages.

    Some of the studies on people dx'd under 5 years show a long term lower risk even at older ages (ie a lower risk of complications at age 30 for people dx age 4 vs 14), but not all of them.
    However, pretty much ALL of them show a much lower risk when measuring in years from diagnosis (the risk of some complications 10 years from a diagnosis at age 4 is about 0% compared to 20+ % in people 10 years after a diagnosis at age 14).

    To me the most dramatic study was on siblings, comparing the sibling diagnosed first, at a younger age, to the sibling diagnosed second (who was older at dx). These people presumably have pretty similar genetics but, and there is probably less of a confounding issue of how long the older people may have had undiagnosed diabetes (because of course, as a person dx'd at 17, there's no knowing if I may have had 5 years of horrendous blood sugar control prior to my diagnosis, but siblings of people dx'd with diabetes tend to have much lower A1cs at dx compared to people without a first degree relative who was dx'd first) ...
    but in this study, 30 years after dx, the older dx'd siblings had a rate of proliferative retinopathy of 53% vs 37% in the younger dx'd siblings (188 people in each group, older dx average age 17 and younger dx average age of 8), and yes that's statistically significant.
    http://www.ncbi.nlm.nih.gov/pubmed/22931229
     
  13. Darryl

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    Interesting, although there could be other factors that are not mentioned in the abstract such as the A1C of each group, and whether kids diagnosed as teenagers control their BG as well as teenagers who have been managing D their whole lives.
    In any event, whether the retinopathy risk is 37% or 53%, both numbers show that their is no protective effect at any age of dx. The only protective effect that has so far been established is a low A1C with low variability.
     
  14. kiwikid

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    Hasn't this been refuted? It certainly didn't work for us - with HbA1c's all around 7 and dxd at 11 months :(
     
  15. SarahKelly

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    Thank you for sharing this.
    I still think that the hard part for me is when I feel like I am the one educating the CDE, dietician, and other staff at the endo clinic about how to utilize the technology available without becoming overly obsessed. I know they believe I go above and beyond, but in actuality knowing the benefit of having my son maintain an A1C of 6-vs-on A1C of 8 makes me know that it is just what we (and someday he) need to do.
     
  16. Helenmomofsporty13yearold

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    I have read that a normal fasting BG is 90-100. I have never read 80-90. I am not diabetic and if my BG dips to 73, I start trembling, get dizzy, feel weak and have a hard time functioning. My body feels a lot better 90-100. My BG did jump once to 190 a half hour after eating a calorie laden muffin after a night of very little sleep (I tested because my whole body felt like it was "buzzing").

    I know you are a very loving Dad doing the best for your child, but it makes me shudder when you throw around numbers like this that may not be appropriate for everyone. Not every child is as disciplined as yours to check her CGMS every 1/2 hour and make adjustments. Every girl has different effects from her monthly cycle. Some children are more insulin sensitive and more activity sensitive.

    Just recently when DD was on shots, she ran only 3km one evening, but did it in as fast as she could. She dropped her bedtime basal at midnight and went to bed with a 180 BG. At 1:30am her BG was 45. I wonder if you have even seen drops like that in your child. Keeping within a tight range would have required an entire days pre-planning for this event which was spontaneous. Even on a pump she needs "cushion room" as some days her body is more insulin/activity sensitive. On insulin-resistant days (PMS, illness, stress) she does not need much cushion. At the beginning of the summer, it took 500 carbs to bring up DD's BG and keep it up (pumping at the time, turned off basals, etc) after 4 days of intense exercise where she lost 4 pounds of body weight (she reduced her eating also during those 4 days). We are not inside our childrens' bodies and can only guess how things are going to work with each event. I cannot imagine how much more difficult it is for those with very young ones to make these guesses.

    Only 17% of the Type 1 community would have even qualified for the DCCT trials and even those folks could not keep up the 7 A1C they worked so hard for. The endos, ADA, etc. are not stupid making their recommendations and they are not out to hurt our children.
     
  17. Darryl

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    Every person is different but statistically normal fasting BG is 73 to 92. I usually quote 80-90 so as to not include the low end.
    http://www.diabetes-symposium.org/index.php?menu=view&source=&sourceid=0&id=322&chart=18

    Of course we've seen days where a 180 drops to a 45 (or at least tries to). Not sure what you mean by it taking a whole day of planning to stay in a tight range, though. We don't plan anything. When the CGM alarms at 80/120 (80/100 when she used the Minimed) she begins treating the BG. Even if the BG drops below 80, she's already eaten the glucose and turned off the basal, and the BG comes back up.

    Nondiabetic BG goals may make you shudder, but others shudder at risk of long term complications at A1C's that many endo's are comfortable with. Every parent needs to decide what is best for their child. I am sharing the information I believe is important, and you are free to do the same.
     
    Last edited: Sep 29, 2013
  18. swellman

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    I have absolutely no issue with the assertion that fasting BG is 80-90 or 80-100. We don't treat flat 80's.
     
    Last edited: Sep 29, 2013
  19. ChristineJ

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    "A truly normal fasting blood sugar (which is also the blood sugar a normal person will see right before a meal) is

    Between 70 mg/dl (3.9 mmol/L) and 92 mg/dl (5.0 mmol/L) .

    Doctors consider any fasting blood sugar between 70 mg/dl (3.9 mg/dl) and 100 mg/dl (5.5 mmol/L) to be normal. But several studies suggest that people whose fasting blood sugar is over 92 mg/dl (5.1 mmol/L) are more likely to be diagnosed with diabetes over the next decade."

    link here http://www.phlaunt.com/diabetes/16422495.php

    This is in agreement with laboratory reference ranges of 70-100mg/dl (3.9-5.5 mmol/L) as normal human fasting glucose.

    Christine
     
  20. DavidN

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    I just learnt that the "low" BG group for adolescents in the DCCT and EDIC studies was 8.0 (vs 7.0 for adults) and something like 10.0 for the "high" adolescent BG group (vs 9.0 for adults). Maybe someone mentioned that but I missed it. Doesn't really change anything but made me feel a bit better nonetheless.
     

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