Dr. Barry Ginsberg: A Diabetes Icon Explains… Everything

Well OK, maybe not everything, but it was pretty inspiring interviewing the endo who led the research team for the landmark DCCT (Diabetes Control and Complications Trial)!

Dr. Barry Ginsberg is internationally recognized as an “iconic figure” in diabetes, blood glucoseBarry_ginsberg monitoring technology and implantable sensors. He’s published over 100 articles in peer-reviewed journals and has received over 5 million dollars in research grants. He recently retired from 15 years as vice president for worldwide medical affairs at BD Medical’s Diabetes Care unit. And very lucky for us, he was generous enough last week to share some of his accumulated wisdom with our community via DiabetesMine.com. He’s so refreshingly down-to-Earth — you just have to read this!


DM) You’ve seen a lot of changes in diabetes care over the years. What do you think is the most important new development underway right now? And why?

BG) The biggest change is recognition that diabetes is important. There’s a new realization among physicians … that injectables are important. They used to threaten patients with the needle.

Along with this comes an epidemic of new drugs. There are about 400 new drugs in the pipeline for diabetes right now, mostly for treating Type 2, including some totally new categories.

For example, a company called ISIS is working on an “antisense RNA” injection that stops the body from making a protein that blocks the action of insulin proteins in Type 2 diabetes. So the insulin proteins stay active longer, and you get more insulin action at every level.

DM) What about the development of a closed-loop system, for example?

BG) For Type 1’s this is very exciting, yes. We are marching toward an artificial pancreas, albeit much more slowly than people think. We have CGM (continuous glucose monitoring), but not yet at an accurate enough level to perform well as part of an artificial pancreas.

Also, the pancreas only lowers your blood sugar, but doesn’t raise it. A healthy body has four different systems to raise blood glucose: glucagon (which hardly works at all in people with diabetes), adrenaline (which stops working when you’re hypoglycemic unaware), growth hormone, and cortisone. The last two work more slowly, over many hours.

When you eat or exercise, a healthy pancreas gets a separate signal from hormones made by the gut that you’re doing this. With a replacement system, you’ll still have to somehow tell it when you’re eating or exercising.

The point is that people are assuming an artificial pancreas will simply “take care of their diabetes.” So far, no artificial organ works better than the body does.

DM) You state that accuracy shortcomings are the biggest deficiency in today’s home BG monitors. What can patients do to offset this problem?

BG) Let me start with what’s great about today’s meters: they require just a very small blood sample, they’re reasonably accurate, and they’re very fast. By “reasonably accurate” I mean just 6-8% inaccuracy for conventional meters, versus average 2-3% inaccuracy in the lab. CGM systems currently have average inaccuracy of 12-14%. Patients generally don’t understand that everything has some inaccuracy built in. All meters are inaccurate to some degree.

With the pricking and waiting, the whole process is still unpleasant, and you do get the occasional staining of clothes. But you’d actually be surprised how many people still use big, ugly lancing devices and complain about how much it hurts.

Washing hands is very important, because Type 1’s are making insulin dosing decisions based on that number. I had an associate yelling at me once because our clinic’s meter was showing her at 300, and she isn’t even diabetic. Turns out she had just eaten a banana, and still had the residue on her fingers.

I like to say that blood glucose monitoring is like baking. If the oven’s at the wrong temperature, the cake won’t come out good.

DM) You’ve recently joined the board of medical advisors of AgaMatrix, the company behind new WaveSense BG testing technology. Can you explain in layman’s terms why you believe this technology is superior?

BG) Imagine trying to analyze a whole big box of marbles with a variety of sizes. You want to know how many are ½-inch across, so you use a sieve to filter out the half-inch marbles. But you still don’t know how many are ¼-inch across versus other sizes. That’s sort of like regular BG monitoring: the sensor runs with constant voltage, so it filters out only one component and ignores everything else.

But WaveSense uses multiple sieves, and therefore gets more accurate capturing of information. It measures at different voltages, so you can accurately figure out what percent of the blood is red blood cells, the ones with no insulin – and the biggest single cause of error in BG monitoring today.

DM) You’re not diabetic yourself. But you’ve had a lot of experience testing your own blood glucose?

BG) Once on a two-hour plane ride, I must’ve tested 50 times, just to see how it was changing. I also once told my students it was so easy, I could do it blindfolded. I wound up with blood on my shirt, pants, and socks — but not on the test strips {chuckles}.

DM) What about glycemic variability? Do your studies suggest that this is potentially more important than just an in-range A1c result?

BG) I honestly don’t know what to make of it. The DCCT data says it’s not important. But I’m not sure how accurate that is, because the blood samples in that study were not taken from meters, so they had no date and time stamp. We had no way of knowing when the samples were taken.

A new study published in JAMA in January does show that high glycemic variability is associated with an increase in some factors that may increase complications – but the data’s not hard and fast.

So if you go only by the hard evidence today, the answer is no. But I think it’s important to minimize glycemic variability. The higher your variability in anything, the harder it is to control. If you come to see me with an A1c of 12, for example, the first thing to do is limit your variability, so instead of ranging from 100-500, you’re only bouncing between 150-300. Then we can work on moving the whole curve down.

DM) What would you tell new patients starting on insulin today? Are fancy new pump features really necessary for avoiding complications?

BG) I think all patients should be on intensive therapy, including Type 2’s. Intensive therapy is the way to go because it’s so much easier to figure out what’s going on: every meal corresponds to a BG value; breakfast corresponds to your lunch reading, and so on.

Fear of injection is actually less than a quarter of the reason why people are resistant to taking insulin. Most times they think it’s too difficult to control, or a sign of “the end.”

We all know that the hard part of diabetes is living with it – the psychological part. The actual administering of insulin is not the hard part. Look at Byetta. It’s an injectable, but it’s still very popular due to the weight loss benefit.

Regarding insulin pumps, it’s hard to rigorously show that fancy features make a difference in overall control. Certainly they make life easier. From that perspective, things like the “bolus wizard” are very important.

DM) What’s the one most important thing you’d like to see every patient with diabetes do?

Come to the realization that they can take charge and control their diabetes.

And also to seek out the best medical care they can. Find someone you work well with, because it’s a partnership.

Most Type 1’s seem to have an internal locus of control for their diabetes, and many Type 2’s have an external locus of control, meaning they let their doctor or educator lead the way.

In a recent study we interviewed about 200 patients new to our practice. We discovered that people with an internal locus of control did well with physicians who took an “advising” versus a “commanding” role, and vice-versa.

Either way, you should seek out a partnership that works for you.


Thank you, Dr. Barry. These are wise words from a diabetes care veteran.

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6 Responses

  1. RichW
    RichW July 30, 2007 at 7:24 am | | Reply

    Thank you Amy. I enjoyed reading the interview and as usual, from your site, I learned a little more. I was a participant in the DCCT study and have thought about starting a blog to talk about the experience. I am now a participant in the Epidemiology of Diabetes Interventions and Complications Study (EDIC). EDIC, a follow up study to the DCCT study, examines the risk factors associated with the long-term complications of T-1 diabetes. I have been very fortunate to have had the opportunity to work with so many talented and dedicated health professionals. Dr. Ginsberg is an outstanding example.

  2. Scott
    Scott July 30, 2007 at 7:42 am | | Reply

    Great input from a veteran in diabetes care. The only issue he really does not address is the relative shortage of endocrinologists nationwide, and why that makes “seeking out a partnership that works for you” significantly more difficult (and will probably be moreso in the future). Still, a great interview!

  3. Michael Park
    Michael Park July 30, 2007 at 9:25 am | | Reply

    Great interview!

  4. Scott K. Johnson
    Scott K. Johnson July 30, 2007 at 11:20 am | | Reply

    Great interview Amy, and thank you Dr. Ginsberg!

  5. Lauren
    Lauren July 31, 2007 at 7:24 pm | | Reply

    Type 1′s can’t really afford to NOT have an “internal locus of control,” or their days are numbered. I’m speaking as someone with a type 1 sibling. My brother has been diagnosed for 15 years, since childhood. He is not well controlled and although he’s in his twenties, the consequences are already catching up to him. This is partly why I am very irritated by parents who treat their child’s disease as if it’s their own. The earlier the kids develop that internal drive to control their own sugars, the better off they will be later in life.

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