Impact of the Diabetes Control and Complications Trial(Dcct)on Management of Insulin-Dependent DiabetesMellitus: a Pediatric Perspective

Abstract

Insulin-dependent diabetes mellitus (IDDM) in childhood and adolescence presents a formidable challenge to pediatric health care providers. On one hand, the severe degree of insulin deficiency compared to NIDDM and the physical and psychoemotional changes that accompany normal growth and development make day-to-day management of this condition especially difficult. On the other hand, results of the Diabetes Control and Complications Trial (DCCT) have shown that the degree of metabolic control that is achieved in adolescents and adults with IDDM has a great impact on the prognosis regarding the onset and progression of microvascular complications.12 This paper will review the background, rationale, design and results of the DCCT, as well as the impact of DCCT findings on the current approach to treatment of adolescents with IDDM. Historical PerspectiveThe discovery of insulin by Banting and Best in the early 1920s was hailed as a "cure" of diabetes, changing a terminal diagnosis into a treatable condition. As children with diabetes survived into adulthood, it did not take long to discover that they faced a variety of devastating degenerative complications, such as those originally described in the kidney by Kimmelstiel and Wilson in 1936. 3 Indeed, IDDM is a leading cause of blindness, end-stage renal disease, peripheral and automatic neuropathy and early onset of coronary, cerebral and peripheral vascular disease. For almost 60 years, clinicians argued about whether better control of hyperglycemia could prevent or delay the development of diabetes-related complications (i.e., the glucose hypothesis).Major obstacles stood in the way of testing the glucose hypothesis, including practical and logistical difficulties in performing a large-scale clinical trial over a prolonged period of time. In addition, clinicians were limited in attempting to safely lower plasma glucose levels using one or two daily insulin injections with urine glucose testing to monitor glucose control. Moreover, there simply wasn't any way to quantitate the level of glycemia in individual patients or groups of patients over time, using urine glucose and rare plasma glucose measurements.

Adolescents with type 1 diabetes can achieve glycemic targets on intensive insulin therapy without excessive weight gain

“…This data suggests that in adolescents with T1D, it is possible to achieve target glycemic control on an intensified insulin regimen without excessive weight gain, and that there is no association between BMI‐SDS and HbA1c or therapy type. Our findings are in contrast to those from adolescents in the DCCT trial which saw a two‐fold greater risk of becoming overweight with intensive management 11 . Contrary to other reports that demonstrate adolescents are a group that have suboptimal glycemic outcomes, 12 our data showed a doubling (14–17 year group) and tripling (10–13 year group) of youth meeting international glycemic targets on intensive insulin therapy.…”

“…Our findings are in contrast to those from adolescents in the DCCT trial which saw a two‐fold greater risk of becoming overweight with intensive management. 11 Contrary to other reports that demonstrate adolescents are a group that have suboptimal glycemic outcomes, 12 our data showed a doubling (14–17 year group) and tripling (10–13 year group) of youth meeting international glycemic targets on intensive insulin therapy. Our team previously demonstrated in toddlers that mealtime structure plays an important role in achieving glycemic targets 13 and it is possible this message in older children and adolescents may assist with maintaining weight whilst meeting glycemic outcomes.…”

A comparison of FreeStyle Libre 2 to self-monitoring of blood glucose in children with type 1 diabetes and sub-optimal glycaemic control: a 12-week randomised controlled trial protocol

“…Internationally, only one in four children with diabetes achieve international standards of glycaemic control (HbA1c < 58 mmol/ mol [< 7.5%]) [5][6][7]. This increases their risk for short and long-term diabetes complications as shown by the Diabetes Care and Control Trial [8][9][10].…”