Danish Steno Study

[xyzzy]

At the GP's yesterday he emphasised cholesterol, blood pressure and weight loss as "just as important" as good BG level control and said that I should read the Danish Steno2 study that measured outcomes over a 13 year research period.

I think it is a pretty shocking study but one well worth reading.

The results of the original 8 year study in easy to read slides can be downloaded here http://www.steno.dk/documents/forskning/afd521/Steno-2.pdf

A follow up study was then done at 13 years. The slides for that can be found here http://www.stenodiabetescenter.com/documents/forskning/Oluf/Steno-2follow-upstudy.pdf

 

[dawnmc]

What does it all mean tho' xy?

 

[xyzzy]

Well they started off with 160 55 year old Type 2's and split them down the middle. One half got the Danes conventional treatment and the other a set of intensive therapies to try and get their HbA1c's, cholesterol, BP, weight and other things far better (see the treatment goals slide in the first presentation)

At the end of the 13 years the results showed

In the conventional group 40 out of the original 80 55 year olds or HALF where dead!
In the intensive group it was 24 out of the 80

The final slide in the second presentation says it all.

That to me is a very powerful message to aim for an HbA1c < 6.5%, loose weight and get good cholesterol and blood pressure!

 

[hanadr]

I skimmed through those slides and noticed that even in the intensive group, the HbA1c and blood pressures were higher than I'd allow myself.
the medical profession, even in other countries seem to set the barriers too high.
In my opinion; I would expect an intensive trewatment to achieve something near NORMAL blood glucose HbA1c around 5% and NORMAL blood pressure120/90 approx.
If they continue to compare ""poor" control with "catastrophic" control, they won't come up with anything new.
Hana

 

[xyzzy]

I skimmed through those slides and noticed that even in the intensive group, the HbA1c and blood pressures were higher than I'd allow myself.
the medical profession, even in other countries seem to set the barriers too high.
In my opinion; I would expect an intensive trewatment to achieve something near NORMAL blood glucose HbA1c around 5% and NORMAL blood pressure120/90 approx.
If they continue to compare ""poor" control with "catastrophic" control, they won't come up with anything new.
Hana

Yes my GP said roughly the same thing as you Hana. You have to remember the study began back in 1995. He said apart from HbA1c all the intensive targets would nowadays be a lot tougher which if you look at up to date guidelines for several countries is the case. From his perspective it's why he wants to fill me full of Metformin, Simvastatin, Ramipril and tell me to eat as low carb as I need to.

Doesn't alter the impact of noting that "catastrophic" or doing what amounts to very little will kill half of 55 year old T2's in less than 13 years! I wonder how many of the 50% would have changed if they had been aggressively told that message?

 

[paul_melb]

Pretty grim stuff but highly motivational....

 

[Defren]

Pretty grim stuff but highly motivational....

I agree. For half in the none aggressive study to be dead just a few years later, shows we can't afford to be complacent. It also suggests that those who don't know how to, or simply won't change their lifestyle upon diagnosis are heading for an early grave. For me who is already terrified of the the outcome of the condition I share my life with, this really has made my head spin. The problem is, many if not all here do at least something, and have changed out lifestyles somewhat, to help us gain some level of control. What about those who don't know any different? It makes my blood run cold!

 

[xyzzy]

What about those who don't know any different? It makes my blood run cold!

That is the truly shocking bit i.e what if you're NOT one of the people you have arrived on this forum or a similar place and don't have that motivation or knowledge. My GP reckons that's 97% of the people he deals with in the same situation as us. I don't especially see that any of us is likely to end up in the 50% unless we go mad and go off the rails. Like Hana I believe if you normalise everything you can then you should run the same chances as a normal person. That's my goal.

Anyway to be honest the discussion I had with him has made me think quite a lot. We can have our debates and arguments about the finer points of dietary control or whatever but that is missing the point as so long as they work they are all valid options. The point to me is how to reduce that 97% to give at least some other poor people the chance we have given ourselves.

 

[phoenix]

One thing to remember is that at the start of this study all the subjects were poorly controlled. They had had diabetes for an average of 6 years already they had an average HbA1c of around 8.6%, high BP, average BMI of over 30, relatively high cholesterol and trigs and all had some degree of albuminuria. So they were all already at huge risk of an early death or if not serious complications.

Relatively few actually achieved the 6.5% HbA1c, their average HbA1c was 7.9% at the end compared with 9% in the conventional group.
The intensive group did get nearer the targets for other measures. They had lowered lipid levels, ( conventional groups was minimally reduced), reduced BP (conventional group also lower but by less) ,greatly reduced albuminuria ( the conventional groups albuminuria had increased)

Results: fewer deaths, heart attacks, strokes, angioplasties, bypasses, kidney disease, amputations, retinopathy, blindness( at least one eye) autonomic neuropathy.
Only on one measure were the outcomes similar. That was peripheral neuropathy; both groups 59% of the subjects suffered from worsening neuropathy.

So a package of targets, medication, diet(increased fish, fruit and veg, lower animal fat) resulted in much better outcomes.
Not surprising that many doctors emphasise cholesterol , trigs and BP and suggest medication to reduce these and ACEs / ARBs to to 'protect kidneys.

 

[Unbeliever]

There may be some hope on the horizon. A few years ago when I encountered some newly apppointed Gps I was horrified
to hear what they had been taught about T2 diabetes.

Yoday I had my annual review and was surprised to find some students there. I had no objection to their presnce but thought it was fair enough o ask hem some questions oo. I was pleasanly surprised. They appeared o have an understanding of the diffficulties in controlling the condition and the importance of all the things which xyzzy's Gp emphasised and bes of all fully understood he importance of self testing glucose levels.

I didn't discuss diet because it is never though to be an issue with my BMI of 19 but they knew that the sterotpe of a T2 is often inacccurate For the first time in a very long time I was not left wih the feeling that I had wondered into a parallel universe in visiting the surgery.
I just hope they are not indoctrinated by the "enemy " before they qualify. I was very impressed. Takes a lot!

 

[xyzzy]

One thing to remember is that at the start of this study all the subjects were poorly controlled.

Trouble is it would appear a lot of diabetics are poorly controlled simply because they haven't been told an appropriate message that would change them or don't want to hear it. That's why the initial diagnosis and the period just after is so critical imo. Get the initial message right and something might be able to be done.

 

[Unbeliever]

One thing to remember is that at the start of this study all the subjects were poorly controlled.

Trouble is it would appear a lot of diabetics are poorly controlled simply because they haven't been told an appropriate message that would change them or don't want to hear it. That's why the initial diagnosis and the period just after is so critical imo. Get the initial message right and something might be able to be done.

Totally agree with you xyzzy. It requires a major change in attitude though. I feel, and this is borne out by many posts on here, that money is actually being wasted in totally ineffecive initial inervenion and "advice"
T2 diabetes , thaks to he bad press is seen not so much as a disease bu as a bad lifestyle choice and those unfortunate to be diagnosed with it have to fight o be taken seriously and o obtain appropriate treatment. It is not just the absence of ueseful advice and information but the false reassurance many receive.Or the "leave it all o Nanny{nursey ] approach.

This is criminal when we consider the possible -even probable -consequences.. It would surely be cost-effective to concenrate resources on he newly diagnosed until they manage to control their own condition in a sustaibnable way.
Having said this I think this was the approach at one time but, unfortunately and perhaps inevitably pressure was applied to shorten his period b efore it could be completely effective. This seems to be what is being proposed again.
Instead of diet and exercise being the focus i think we will see drug therapies being inroduced sooner.

I suppose all that could be done is to include low or reduced carbing advicein the starter pack and links to his forum given to the newly diagnosed! It is surely completely unethical to fail to warn patients of he poenial seriousness of the condition..
Often this is self -defeating because patients are confued. They are often aware of he possibility of complications but have no idea what hey can do to prevent them . Many are unaware that here is anything at all that they can do to conrol their condition for themselves - ecept the famous NHS diet , of course.

It reminds me , in a sense, of the "sin " of alllowing children to leave school . illiterate , or nearly so . Often their parents have no idea that this is the case because the child can have quite good school reports with the elephant i n the rooom being completely ignored. I have always felt that unil the child can read adequately hen almost everything else they do at school is irrelevant,, What are we condemning them to otherwise.
Same with unconrolled diabetes . Teach us the alphabet first. Give us the tools to control our diabetes.Otherwise what is i all about? Migh as well stick a n elastoplast over the area you imagine your pancreas to lbe :lol:

 

[xyzzy]

It is surely completely unethical to fail to warn patients of he poenial seriousness of the condition.

Agree but it many ways it's ethics that are getting in the way. If you read that joint American / European self management doc it makes some very good suggestions about encouraging an aggressive approach for the newly diagnosed. We can dispute what "aggressive" means in terms of a dietary statement but you get the point.

The problem is the guidelines are not enforced. Someone wrote today on a thread that overweight people are no longer going to be told they are overweight as its been decided it will offend them. Now my attitude is that many people get overweight because many have a predisposition to get overweight not that they are evil lazy people. Doesn't alter the fact that they are overweight though does it? It also doesn't alter the fact that losing weight and adopting a good diet will sort quite a lot of their problems out either. To me it is fine to tell someone they are overweight as a statement of the bleeding obvious and that they need to lose weight or else the Grim Reaper is just round the corner. So long as you say "you are overweight" and leave it there without making any assumptions about how that person got overweight it should be fine. As you say its completely unethical not to tell people these things.