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Prof David Nathan : intensive therapy in type 1 diabtetes

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A thirty-year follow-up on the benefits of intensive diabetes therapy




Hello! You’re on MD-FM INSIGHT, the first medical web radio. Today we’ll be devoting our "Question & Answer" program to the long term treatment of type-1-diabetes.



During the annual meeting of the American Diabetes Association in Chicago last June, long-term follow-up data from the Diabetes Control and Complications trial were presented. We interviewed Prof. David Nathan, director of the diabetes centre at the Massachusetts General Hospital, in Boston, and co-chair the DCCT/EDIC study.



First of all Pr. Nathan, can you give us a bit of background on what is this DCCT study?


Nathan-1: “The DCCT story, which at this point is a very long story, began in 1982, when the diabetes control and complications trial started. The intent was to examine whether we could reduce the development or the progression of diabetic complications, including the eye complications (retinopathies), nephropathies (kidney complications) or neuropathies (nerve complications). And the question was whether we could reduce them with intensive therapy, which was aimed at lowering glucose levels and hemoglobin A1c levels, which represent chronic glucose levels, as low as possible. So the DCCT study itself ended in 1993, at which point we demonstrated a substantial effect on early complications of type 1 diabetes.”



Ok… and after 1993?


Nathan-2: “In the last twenty years, in the observational follow-up study, which is called EDIC: Epidemiology Diabetes Intervention and Complications, we’ve demonstrated that the early results continue, and that is that we now can see differences not just only in early complications but in the more severe complications that are of course of more importance to people with diabetes. These include a loss of kidney function, severe eye disease and the need for eye surgery… Heart disease is reduced as well, so all of those serious complications are reduced, as were the earlier stages of complications.”



And by how much are these complications reduced?


Nathan-3: “Depending on which complication we are talking about, there are slightly different levels of reduction. However if we take them altogether, it’s about 50 percent, so about one half of the complications that would otherwise occur do not occur in people who use intensive therapy.”



And out of all these complications, would you say there is one that must be reduced in priority?


Nathan-4: “It’s difficult to choose which is the main complication… Not all patients get all complications, it’s been difficult to determine whether loss of vision is more important than loss of kidney function and the need for dialysis and transplantation, or whether it’s a heart attack –those are very difficult things to measure one against the other. So clearly: saving lives is very important. We are not yet ready to talk about mortality, but we will be ready to talk about it in the next year or so, as we get more and more results, however I think that reduction of heart disease by 57 percent, reducing heart attacks or stroke –I think that’s extremely important… Probably the most important diabetes-specific complication is probably kidney disease, because once you get kidney disease then people also get heart disease, increase their blood pressure –there are a lot of complications that then start accelerating after kidney disease develops. So you can pick whichever one –they are all reduced about 50 percent. ”



So what’s your key message from both these studies then?


Nathan-5: “The key message that has come out of the DCCT and its long term follow up study, the EDIC study, is that lower HbA1c, lower glucose levels are better glucose levels. We need to start this therapy as soon as we can after the diagnosis of diabetes, because then you get the maximal effect. However, even if you start this later in the course of diabetes, there’s a benefit that patients will have.”




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Previous editions


Best of Science in Nutrition 2013: Yogurt for a healthier diet (EB & IUNS 2013)

Best of Science in Nutrition 2013: Yogurt for a healthier diet (EB & IUNS 2013)
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