Is the Benefit Worth the Cost? Technology Impact on Type 1 Diabetes

William B. Zipf MD, FAAP | Medical Director of COPEDS

During my 45 years of involvement with the management of children and adolescents with Type 1 diabetes mellitus, it is clear to me that throughout this last decade there has been a paradigm shift for patients, parents, and physicians. That shift came with the unanticipated surge of new technologies being applied to diabetes management.

During the latter half of the twentieth-century research was revealing the devastating pathologic impact of persistently elevated blood glucose on organ systems occurring with traditional accepted therapy. However, at the same time, hope was emerging during the early part of the 21st century that new technologies held the promise for providing the degree of glucose control needed to prevent the disastrous consequences of type 1 diabetes. Indeed, we are now in a new “era” for patients, parents, and physicians and as with all “eras”, the change is not always smooth.

In the 1970’s it was easy to manage diabetes. As a provider, you had only two types of insulin (NPH and Regular) and totally inadequate measures of control being the cumbersome qualitative urine check. Our best tools for determining if control was adequate were paying attention to the overall growth of the child, the frequency of hospitalizations and/or episodes of hypoglycemia. Physicians had very few tools to manage glucose and few tools to judge adequacy or need for adjustments. We correctly told our patients at the time of diagnosis that managing diabetes would be easy for them. It would interfere with their life just two times a day when they would need to stop and inject a pre-determined amount of insulin and require a diet that limited carbohydrates but was basically the diet we should all be on. “Easy Peasy”. When you have only a few tools and no information, it's as it's said, “when your only tool is a hammer, every solution is a nail.”

In the 1980s we had Hba1C values and in the 1990’s we had home blood glucose monitoring that could be obtained rather painfully a few times a day. But, In the last 15 years, there has been an explosion of technology changing both our ability to assess control and providing multitudinous options to try to improve control. We now have new long-lasting insulins with extremely smooth 24-hour profiles and insulins that can be used for better mealtime control as they are absorbed ultra-fast. We have multiple types of insulin pumps that can deliver a continues subcutaneously infusion of insulin which can be adjusted to nocturnal, morning, afternoon and evening needs. Separate insulin delivery programs can be provided to the pump for different degrees of activity. The pumps have push-button ability to calculate and deliver pre-set insulin to carbohydrate ratios following carbohydrate counting for each meal and snack. We have almost pain free home blood glucose monitoring with traditional finger sticks but also continuous glucose monitoring systems each with different profiles of advantages and disadvantages. We can obtain 288 data points per day and multiple thousands of glucose levels per week for an analysis of nocturnal, pre-meal, mealtime and post-meal glucose control. We can compare glucose patterns meal to meal, week to week and month to month. When this data is combined with exact daily carbohydrate counting, journaled information on meals, activity and sleep patterns, a degree of glucose control never imagined is achievable but decision making is much more complex.

The improved control needed to minimize risks for diabetes complications is unknown but the recent ADA guidelines for ages < 18 is having an HbA1C of < 7.5%. This is achievable but only if the patient and parent now make diabetes a major part of their life and allow it to be an all-day affair. To take maximum advantage of these systems the patient and family first need to develop expert carbohydrate counting skills and cannot just guess. The patient and parents need to discipline themselves to either physically or at least mentally “journal” each day’s meals and activity for comparisons to glucose values and insulin doses being used. They need to monitor glucose profiles to determine how each mix of nutrient and carbohydrates in a meal affect glucose patterns. They need to habituate the practice of blousing with each ingestion of carbohydrates during the day. The family needs to add to the day’s regime a daily moment to review the glucose patterns and learn how to make adjustments to the pump settings when patterns of glucose are repeatedly too high or too low. If the physician has all the relevant information needed and has the time to analyze the meal to meal, day to day, week to week and month to month patterns he/she then is in a position to “fine-tune” the system to achieve the glucose control desired. He/she then needs additional time to show/explain/instruct the patient and make these further pump/diet adjustments. Further instruction is needed to be sure the patient has an active back-up plan for management when the devices fail and when the patient changes their activity/sport. The physician needs to be sure they themselves are adequately trained and experienced with all the different devices and are able to take advantage of the specific device’s built-in capabilities.

Because of the intensity of patient and family care needed to take advantage of this new approach to diabetes management, the physician needs adequate training in psychological tools such as motivational interviewing (MI) and cognitive behavior therapy (CBT) so as to provide the needed psychological therapy to maintain patient engagement with the multiple tasks needed to realize the potential of the systems (or at least not disrupt a therapists efforts to improve health behaviors because they don’t understand these tools). Studies show that with this effort, marked improvement can be achieved.

Allowing the pump to simply administer insulin without this effort does make diabetes a little easier as separate injections are not needed but overall glucose control is not achieved and the desired long-term goal is not met. Just wearing a pump may make one think they are “high tech” but it does not allow for better glucose control.

Thus, engagement in this effort is associated with higher costs. Costs measured in dollars for supplies and equipment. Costs that are measured in parent time, energy, adherence, additional education, and frustration. Cost to the patient that is measured in taking away from childhood, some of what childhood should be. These costs are also measured in the physician's time, advanced education and phone call management.

Is the benefit worth the cost? Having seen the devastation of lives, hopes, and dreams associated with prolonged poor diabetes control, the answer is a loud and definitive YES. Is the cost worth the time and money yet to be spent to find a cure for all these patients? YES.