As hubby and I sit on the couch watching "The Biggest Loser" on the tube, he always says "Oh it's easy to lose weight if your only responsibility for 6 months is to stay at the ranch, exercise with a personal trainer, and eat the food that is provided without having to pay for it or actually work for a living." The truth is he is right. And while I applaud those people who struggle with their weight on the show, I fear for their continued success once they leave the "safety net" of the show.
So what does this have to do with the landmark DCCT trial ? I liken the DCCT trial to the ranch. All DCCT study patients were prescreened for any pre-existing mental health or social conditions that would keep them from being able to maintain good control of their diabetes. I'm sure ABC carefully screens Biggest Loser participants for the same criteria - excluding any with undesirable mental health or social conditions.
Everyone in the DCCT was provided diabetes supplies at no cost to them. This included insulin, syringes, insulin pump supplies, meters and test strips, etc… everything but food. When you consider how expensive this stuff is it is no wonder that only 5% of PWD can possibly attain and sustain DCCT-like levels of blood sugar control. In this case the Biggest Loser actually does provide the food but also the high tech gym and equipment, swimming pool, trainer etc.
Finally, DCCT patients in the intensive treatment group all got monthly visits to the diabetes doctor and weekly calls from the diabetes nurse to make constant adjustments in their daily management aimed at keeping blood sugar levels in tight control. Again like the ranch in that the participants meet daily with their personal trainers and make constant adjustments to their exercise routines and diet.
At the end of the season there is a "Biggest Loser" who wins $250,000. At the end of the DCCT -which ended after a decade in 1993, there were some "Biggest Winners". I think each one of us here at TuD gained something from the trial. The DCCT proved that in a select population, given ideal conditions, tight blood sugar control improved quality of life, and aided in the prevention of complications. To me that's worth a lot more than $250,000.
I think you have to be careful how you couch the results.
The DCCT is just huge huge huge in how it revolutionized the focus onto tight control.
The DCCT "goal" was 6.0% A1C. You are right that is a very aggressive target and not everyone will reach it.
Of the DCCT "Intensive" group, only a tiny fraction actually achieved an A1C of 6.0% or less.
Despite the difficulty in hitting that target, the DCCT results showing that risk for the microvascular complications, is a strong function of average bg or A1C, is hugely important. There have been huge advances in the past 30 years in preventing/delaying complications for huge swaths of the diabetic community as a result of this now crystal clear relation, and the increased availability of home bg testing and intensive treatment regimes.
Yes I agree Tim. But I wasn't actually couching the results. What I was saying is given a select population of PWD. In this case motivated, 13-39 year old volunteers who were given every advantage of medical care, access to education and cutting edge technology etc. the decrease in complications is staggering and certainly something to emulate. At the same time to paint the entire population of PWT1D with the same brush and expect them to duplicate a task without the educational, medical and financial support is unrealistic. Especially if one paints with too broad a stroke and includes people outside of the age range and with the mental health or social conditions which were purposefully excluded by the original study. JMHO
A long time ago, when the DCCT results were first released, I made this argument to my endo at the time. He refused to understand that, without the social support the DCCT community provided one another and the economic support the study provided, it would be nearly impossible to maintain the same level of engagement. Of course, he didn't listen to me, but since when do "the great and powerful M.D.s" actually listen to Ph.D. students? Shame, since if they actually bothered to read psychology literature before embarking on the DCCT, they would have known that I'm right, since psychologists have known this for...oh...decades.
Twenty years has passed since the DCCT was reported. Things have changed. Patients in the DCCT that used conventional therapy (insulin mix) had A1cs of 9%, but those with intensive therapy (MDI) had A1cs of 7%. We have much better insulins available, we better understand the role of carbs, we have much better pumps and we have readily available knowledge. I think we can certainly aspire to have most PWD achieve closer to 6% A1cs. I believe that the primary reason that few PWD fail to achieve better control is benign neglect in the system. Most of my doctors have actually told me to target an A1c of 7%, some actually wanted me to raise my A1c.
Agreed Brian, and my endo was concerned with my 5.7% until I showed her the dexcom data demonstrating infrequent hypos. But I am one of the "lucky" PWD with access to a CGM and insulin pump and education to use them effectively.
Although 20 years has passed since the DCCT results were reported and we have newer, better insulins, pumps, bs monitoring devices, education, and understanding, only 5% of PWT1D achieve and sustain DCCT-like blood sugar levels. I think that speaks to far more than just benign neglect of the system.
I did put in a distinction of T1D because the DCCT focused on that D population but I'm fairly sure the 95% fail rate also applies to T2's.
There is a variety of reasons why most PWD don't obtain DCCT-like results, and many of them have been described here. The artificial cocoon in which the DCCT subjects lived during the study, poor attitudes and lack of up to date knowledge in the medical community, and the other factors -- they all feed into this.
Notwithstanding all that, we DO have far better tools available today. "Available" is the operative word. The tools certainly exist, but one must have the both the means and motivation to "avail" themselves of what's there, or nothing will make any difference.
I watch biggest loser Australia while working out. Actually they pick some specifically with social issues because its entertainment first. There is drama and rating in struggle. Its a popularity contest partially where people manipulate on those week(s) they fall behind. There is a cheat though,most of the winners are young cause its really only academicly a number. Most of all the last ten are in good shape.
The gist of your blog-article is correct. I would add its not those who avoid trouble that have long term success but those that recover and mentally internalize their mistakes the best.