Intensive diabetes treatment and the Diabetes Control and Complications Trial
The Diabetes Control and Complications Trial (DCCT) was an exhaustive survey of almost every aspect of modern diabetes treatment. Aware that most diabetics worry about the kidney, heart, eye and other disorders associated with diabetes at least as much as they do about short-term blood-glucose levels, the study’s architects set themselves the task of identifying the treatment options that brought down the risk of specific complications as well as just maintaining glycemic levels close to normal.
What they found was that the two goals are really the same. It’s precisely by maintaining glycemic levels as near-normal as possible, through rigourous monitoring and frequent injections, that patients improve their odds of avoiding the debilitating and life-threatening complications of diabetes. The only question that remained was, how does that kind of intensive therapy affect the patient’s quality of life?
The study began by dividing 1,441 volunteers, adults and adolescents of both sexes with diabetes, into two groups. The conventional treatment group would receive one or two insulin injections a day, daily blood or urine glucose monitoring, dietary instruction, and clinic visits every three months. The intensive group would receive at least three insulin injections per day or a constant subcutaneous infusion, blood glucose monitoring at least four times a day with algorithms for dosage adjustment, and close monitoring of diet and exercise. Once a week they would test their glucose at 3:00 am, and they would visit the clinic at least once a month as well as keeping in frequent contact by phone for treatment reviews.
The volunteers ranged between 13 and 39 years old, with an average age of 27. They had had diabetes for an average of 5.5 years, and were followed up for an average of 6.5 more.
Quality of life was assessed by three different questionnaires filled out each year by each volunteer. The first was a diabetes-specific test that rated patient satisfaction, impact, diabetes worry and social/vocational worry to give a quality of life score on a scale from zero to 100. The second was a 90-item test that’s widely used to measure psychiatric symptoms of stress. Finally, a 36-point test assessed the patients’ perception of their ability to function, mental health, general health, fatigue and pain.
The study found that intensive treatment patients were, if anything, marginally better off psychologically than their conventional counterparts. Their average quality of life score (78 out of 100) was exactly the same. They rated impact and satisfaction the same, and expressed more or less the same degree of worry. Their perception of their own health was marginally better than that of the conventional group, and also better than at the beginning of the study.
Psychiatric symptom scores were also the same or slightly better than conventional patients, and the group showed only about half the rate of serious psychiatric illness. There were more than twice as many suicide attempts among the conventional group, though the number was not significant in either camp.
As a group, the DCCT volunteers remained psychologically healthy throughout the trial. Intensive treatment required more time and attention, but also gave patients better glycemic control and a sense of taking charge of their situation that seemed to balance things out. Hypoglycemia is more common with intensive treatment, but that was not shown to increase most patients’ anxiety.
The designers of the study point out that many of the intensive group strayed off the primrose path at some point in the survey and let their treatment go a little. But, they say, this is not a cardinal sin; patients can and should be open to modifying their treatment regimen from time to time to keep it in tune with their lifestyle. It’s a question of individual choice.
They also point out that intensive treatment may not be for everyone. Volunteers in this study were mostly educated people who had accepted their condition and the demands it placed upon them. Their generally positive reaction might not be the same in patients who deny their illness, who are not supported by family and sympathetic doctors, who are already upset or who don’t have access to health care whenever he needs it.
Intensive insulin treatment is a life-saver, delaying the onset of complications and slowing their progress when they do occur. But, say the Diabetes Control and Complications Trial (DCCT) doctors, it’s only for those who understand it and are ready for it.
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