ADA’s Kahn Responds. Speaking for Whom?

I’ve received an email reply from Richard Kahn, Chief Scientific Officer of the American Diabetes Association, whose seemingly anti-diabetes-technology comments at a recent conference have created quite a storm.

He encouraged me to post his email, and thus I do so here, unabridged:

I’ve looked at your web-site, and certainly part of the answer to your question is that your own biased and inflammatory reporting contributes greatly to the mis-perceptions surrounding my talk. For the record, the talk I gave was exactly as it was written. There were not “many asides” — not even one, and I don’t understand how ones “demeanor” influences matters when I read the talk verbatim. Also, what do you mean by a “cryptic” speech and “plain vanilla”? Don’t those words seem contrary to the many quotes you provide and language you use that suggest otherwise?

Of note, you seem to have many quotes from individuals as well as your own reporting, but not one word on the actual content of the paper itself. What sentences do you find to be wrong (and why) ? Rather than serve to incite your viewers in a fashion unfair to me and the ADA, perhaps you should have a discussion on the actual ideas and concepts in the talk? It that asking too much?

Moreover, I don’t think ” everyone was stunned,” since innumerable people who actually heard the talk, or read it, applauded my comments in subsequent written and verbal interaction. As for why some in the audience came away with a negative feeling, there are many possible reasons. Perhaps it would be best for you to ask them directly. Of course, in addition to getting their feelings and perceptions, it would be valuable to learn what exactly they disagreed with. After all, its the actual talk they had problems with, or so they say. Yes, you’re welcome to post my comments.

Yesterday’s post was directly reporting on conversations with audience members — highly informed, industry-connected people who were quite upset over Kahn’s speech. I had also printed out the full 15-page script of Dr. Kahn’s talk, and pored over it myself.

As I was reading, I found myself questioning, whom is he speaking for? Here are some excerpts (highlights and asides added by me):

After a long introduction to the evolution of diabetes treatments, he says, on page 5:

“Although patients were now, in the ‘80s, routinely asking questions, and physicians could no longer get by easily without any discussion of treatment options and effects—our health care system was still structured to pay any cost incurred, regardless of whether the service was necessary, appropriate, or even if there were no robust studies showing clinical benefit.

Aren’t patients still struggling to get the basics covered?

Costofcare

“In the late ‘80s, in diabetes care, self-monitoring of blood glucose was simply a given. That is, it was of virtually unquestioned benefit, although still not commonly done by most patients. And a similar benefit was bestowed to nearly every other office-based practice related to diabetes care. Tests, procedures, drugs—whatever got approved—was marketed as if there were no shortcomings, no patient who couldn’t benefit, no limits or constraints to their use, and most important—everything was well worth the price—any price.

No limits on coverage? Has this been anyone’s experience, ever?

On page 6:

“In a totally unconscious and unwitting confluence of circumstances that would feed on each other, patients wanted health care at any cost, clinicians were ready and eager to deliver therapy with virtually no constraints, industry couldn’t deliver novel tools fast enough, and payers (particularly employers) had no choice but to pony up.

Then, in what appears to be an about-face, on page 7:

“Recent reports suggest that only about half of US adults or children receive care consistent with current recommendations. In other words, the technology, medications and information are all there—but they are not getting to the patient. We seem to have what we need, but putting it into routine practice seems to allude us.”

So the technology IS necessary? And didn’t he just imply that the problem is, patients are being showered with unnecessary and costly technology?

And on page 8:

“The ‘90s also gave birth to many other advances in technology without which we would have made little progress in controlling the ravages of the disease…. They have certainly saved lives, improved many more lives, and made diabetes manageable for millions of people. Yet in some instances, for example self-monitoring in type 2 patients on oral drugs, the technology was not preceded by any long-term, randomized controlled study showing benefit. Of note, for that technology, even now, we do not have robust proof that the technology works in such patients, yet Medicare is spending over 1 billion dollars to provide it.

Two questions: 1) What about the landmark DCCT study showing that tight glucose control, achieved in large part by using self-monitoring, does improve outcomes? Does this knowledge not apply at all to people with Type 2?, and 2) How many limbs and lives are lost every year to uncontrolled Type 2 diabetes because the patients were not aware of their high glucose levels?

Then, on page 10:

“Insulin delivery devices and more sophisticated glucose monitoring devices were introduced, but medicine, as I’ve just reviewed, could no longer embrace the simple construct of, ‘if you make it, they will buy it.’ Technology introduced in recent years and in the foreseeable future, undergoes much more scrutiny. The value proposition, cost-effectiveness, and most important, the need to prove real benefit are concepts that have become no less of concern than showing the technology actually works*.”

“… For example, I believe the sale of insulin pumps or continuous glucose monitors would soar if there were a long-term, randomized–controlled trial showing that either of these technologies really do benefit people with diabetes, and are worth the added cost.

What do you think that means?

Further, on page 12:

“A technology that gets the 70% or so of people with diabetes who are not taking their medications as directed, to start taking their drugs like they should, would much more likely have greater benefit than another monitoring or insulin delivery device… And my bet is that another gadget that adds complexity will receive far more scrutiny, and have many more hoops to jump through, before any health plan or clinic approves its use.

Wow. Is he trying to scare us?

In conclusion, on page 15:

“All that I’ve said is certainly not meant to scare or criticize. We must not disparage technology, nor slight its contribution. We should, however, more fully appreciate that the nature of American medicine is changing. The years of unlimited spending and the ready acceptance of any technology that simply works* are drawing to a close.

*If the medical technology works, why wouldn’t it be a priority for patient care??

Hence, my takeaway from Dr. Kahn’s speech is that his words do not read like the words of a chief advocate for diabetic patients, but rather like a chief advocate for health insurance payers — trying to drive down their own costs by denying support for new technology, in particular at the expense of Type 1 diabetics.

Are Kahn’s sweeping comments, calling into question the value of all glucose monitors and insulin pumps, really in patients’ best interest? I think not. This is my personal opinion after analyzing the text. I realize that others may agree or disagree. What’s your take?

Advertisement

55 Responses

  1. Lili
    Lili November 11, 2007 at 10:57 am | | Reply

    Sarah, I don’t believe these studies that show testing made little difference for Type 2s. As far as I can tell, they just told them to test…not what to do with the information. Well, of course they need to know that to get any information, so I wasn’t surprised by the results. What I have seen is testing work for Type 2s who knew what to do, again and again.

    I’m not sure you said the speech was not about Type 1 with regard to technology, but if you did, I encourage you to write to him and say that. He will assure you that it was about Type 1.

  2. Amylia
    Amylia November 11, 2007 at 7:04 pm | | Reply

    Thank you, Amy, for posting this. As a type 1 diabetic since childhood (for 19 years), I can’t believe this man in any way represents an advocate for diabetics. What a crock. I am so angry at Kahn and the Halle Berry’s of the world, people who should be fighting the good fight along with us instead of muddying the waters with rhetoric and bullshite.

  3. Bennet
    Bennet November 13, 2007 at 5:08 pm | | Reply

    I don’t know who this guy is speaking for but in 06 ADA payed him just shy of a half million in compensation and benefits.

    What does ADA rank and file members for – they got him?

    Page 70

    http://www.diabetes.org/uedocuments/2006_990.pdf

  4. Dan
    Dan November 14, 2007 at 9:26 am | | Reply

    I am a type 2, not on insulin. I certainly have no idea what type 1s go through, but I imagine it must be difficult to manage. I agree they shouldn’t be lumping type 1 & type 2 together. They may be the same end condition, but result from two different causes.

    As for studies showing that monitoring doesn’t benefit type 2s, it was just a matter of collecting data. If you just collect data and do nothing with it, it won’t help. The monitoring is NOT the problem, but failure to act on the the data.

    I have consistently kept my A1C under 6% with minimal meds. By monitoring how different foods affect my blood sugar, I’ve discovered what I can eat and how much. One day I hope to get off my meds. In my interaction with other diabetics, I’ve discovered that foods affect people differently. What jacks up my blood sugar, may not jack up someone elses. The only way to know is to test and then act on what the data shows.

    Of course, I’ve ditched the ADA diet since I’ve discovered it’s a guarentee of high blood sugar. The ADA just wants type 2s to blindly follow its diet and take their meds. With no monitoring, no one will know that the ADA approach isn’t working until they end up with nasty complications. The ADA lost all credibility with me a long time ago.

  5. jim snell
    jim snell October 30, 2011 at 10:25 am | | Reply

    I have general and personnal comments here on the ADA.

    1. If their program, policies and mis directed help were realling having some positive effect, the rate for type 2 diabetes insulin resistance diabetes would not be exploding here and around the world. If it was doing some good increases should be in the single digit per centages up or down. That is not the case.

    2. Life style blame is bull shit and unacceptable lazy science. The ADA should no better.

    3. Liver issues of excessive glucose release have been identified that in fact load up human body and cause type 2 diabetes. The ADA has done zero about this. I was almost dead from this and finally after being on “more insulin” both liquid and starlix, glyburide et all – 26 years to be exact, got off, found metformin taken properly on a timed basis shuts off liver dawn effect etc.

    4. How much money of all funds spent on reserach are really spent on type 2 issues which constitue 80 per ecnt of the diabetics. Type 1only constitute 15 to 20 per cent.

    5. ADA and its cheerleaders keep promoting the pancreas – its your insulin is not working correct when in fact a multiorgan set of liver, kidneys, gut/intestine, thyroid run this exoctic collection of organs and hormones etc. Yet the current thinking is locked on target like a heat seeking missle leading to rot out of the body.

    6. While life style may or may not have causedones type 2 diabetes, given the latest knowlegde on human skeletal muscle cell operation and glucose storage, exercise and carbs control are key to ensure that the energy balance on a human body are close to a null so as not to overfill all the glucose storage of the body.

    7, Hearty exercise is the onl,y thing that gets rid of the liquid energy glucose. Insulin does not. Insulin simpliy enables the storage of glucose into the liver, fat, skeletal muscle cells IF there is still room. WHen there is no room, Insulin resistance is turned on causing glucose to backup in the blood system as thete is no where to go.

    8. Adding Actos and even more insulin hoping to stuff more glucose into the cell storage cites causes unbelievable trouble. Here Life style changes of regulating carbs and ensuring energy burn match up can help alleviate the situation. If though the liver is misbehaving and constantly stuffing in excess glucose, diets are meaningless at this point. I was on 1200 calorie tight diet, no sneaking snacks or booze and my weight climbed to 330 pounds till liver arrested and carefull monitoring by finger stick and later CGMS and preventing BG dropping below 100 so as liver kept idled on glucose add.

    My book At the Precipice by Jim Snell details all of this in better detail.

    I am fed up with the non science, mis information and nonsense peddled by those who should know better.

    Why Type 2 Diabetes is such a mis understood poor boy of the medical business escapes me but this mess is going to get worse before it gets better.

Leave a Reply