Retinopathy Prevalence Decreasing in Diabetic Adolescents

I’ve had T1 since the very early 80’s.

The standards of care have improved so incredibly much since my diagnosis. And the statistics are really beginning to show this, the marked decrease in complications (or at least the fact that complications are no longer guaranteed just a few years after diagnosis) as home bg testing and intensive bg control techniques become the norm rather than the exception.

Just a few years ago the word from the medical establishment was: “After 20 years of diabetes, nearly all patients with type 1 diabetes have some degree of retinopathy” .

But today (quoting from a summary): Prevalence of retinopathy dropped from 53% of 342 patients assessed between 1990 and 1994 to 38% of 517 patients assessed between 1995 and 1999. Incidence continued to decline in subsequent time-stratified groups, with a 23% prevalence recorded for 604 patients assessed between 2000 and 2004 and a 12% retinopathy prevalence demonstrated in 567 patients evaluated between 2005 and 2009 (P < .001).

The short summary is here on Medscape. Complete article to be published in Diabetes Care.

What I thought was most interesting about this study was that it didn’t seem to find much difference in people treated with MDI vs. a pump. While they did note that people on pumps had slightly better results, the difference wasn’t statistically significant. NOW, it will be interested to see if the advances in pump therapy (namely, the ability to delivery smaller quantities of insulin which has really changed in the past 10 years or so) will drive these numbers down further.

I’m not so sure that it’s the actual insulin delivery mechanism that matters in the improvements we’ve seen in the past 30 years. (I think you must’ve been diagnosed about the same time as me.)

It’s the whole approach of “we’re gonna work hard to keep bg’s in check” that wins big time, something that wasn’t possible until the 1980’s when home bg testing became available, and didn’t catch on (attitude wise) until the early DCCT published results in the 1990’s.

e.g. the big win for me was switching to MDI in the late 80’s. It’s such a different attitude towards control. Of course back then the modern fancy pants insulins weren’t available but even using R and N I saw such a huge improvement not just in my bg’s but in my quality of life. No longer was I taking a single shot in the morning that would determine what I had to do for the rest of the day.

I’m very glad to see studies like this being done! I almost wish they would update the DCCT, because things now are just not comparable in the least to even 20 years ago when I was diagnosed. Preschoolers now (and anyone, really) who are going onto pumps and CGMs within months of diagnosis just can’t be compared to those of us who grew up with one or two shots of R and NPH a day and testing only four times a day before meals (this was the standard when I was diagnosed in 1991) in terms of their risk of developing complications. I think that, even given teh same A1c levels, control today is probably better than it was back then.

Well, I doubt we will have a DCCT equivalent done. Up until the DCCT there was actually a huge debate about whether blood sugar control had any effect on the development of complications. The ADA was actually set up by a bunch of physicians to counteract the influence of people like Joslin who argued that patients should tightly control their blood sugar. For the next nearly 50 years, there was no conclusive guidance that blood sugar mattered, patients were told to just go about their lives and that complication happen to diabetics… The DCCT (1983-1993) finally conclusively showed the relationship between blood sugar control and complications, but it mostly examined patients (1,441 of them) who had A1cs > 6%, in most cases much higher. The complication rates were significant. Today, most diabetics are better controlled and like Tim notes, complication rates are much smaller. Unfortunately, this makes it unlikely we will have a DCCT 2. We already have conclusively proved the relationship and any further study would by necessity need to look at lower complication rates and need to recruit 10,000-100,000 patients in order to have statistical results that are any better (particularly if the study looks at A1c < 6%).

I think the DCCT is still extremely relevant. Most diabetics today still have A1C’s above 6%. Yeah there is a prominent (on the internet and on tudiabetes) group of overachievers who do better than that, but in the general population of diabetics they are still negligible and not that much greater in number than they were in the 80’s/90’s statistics.

Note that the DCCT required very low or nonexistent C peptide to participate in the study and (related) had to be past the honeymoon. So those who overachieve with little effort, because of remaining natural insulin production, are not in there to any great extent. I think that’s fine. The overachievers can run in their own little circle while the rest of us slog through the trenches, and that’s fine as long as the studies are looking at us in the trenches.