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?

55 Responses

  1. Terry Keelan
    Terry Keelan November 7, 2007 at 10:08 pm | | Reply

    My take is that Dr. Kahn is saying we should be cautious about getting so caught up in the latest technology that we neglect to actually take care of ourselves. Having the latest and greatest CGM won’t control my blood sugars or prevent complications – I still have to DO something with the information. The most sophisticated pump in the world only does what I program it to do – I can’t rely on it to take care of me on it’s own.

    It’s worthwhile to reconsider whether our gadgets are helping us or holding us back.

    Terry

  2. Lauren
    Lauren November 7, 2007 at 11:59 pm | | Reply

    Is it just me, or did Kahn’s speech manage to be highly offensive to both type 1 and type 2 diabetics?

    Speaking as a type 1 striving for tight control (which is, according to just about every piece of scientific literature on the subject, the best way to avoid complications down the line), I cannot believe any diabetes advocate could breathe the words “our health care system was structured to pay any cost incurred” with a straight face. The idea that the diabetes community is showered with superfluous technology is laughable. Everyone has a story about not being able to get test strips and glucose monitors, let alone pumps, covered by their insurance plan. (In my case, insulin is not covered, because it isn’t a “generic drug.”)

    Speaking as a medical student and someone who has worked with type 2 diabetics, I can say that access to glucose monitoring technology in conjunction with diabetes education can have a powerful effect on compliance. Type 2′s struggle with misinformation every day. They may be told that they are “borderline,” or their diabetes is not serious. Often type 2′s are not instructed how to interpret their glucose readings. They not only need the technology to self-manage, they need the training to understand its use (something else that insurers balk at covering).

    Kahn’s idea of “costs” are monetary. (As patients, we see “costs” differently — in terms of our health.) But, to logically extend Kahn’s argument, aren’t the complications of diabetes far more expensive (in terms of dollars) than their prevention? Good control is a preventative measure, and technology is a means to achieving this goal.

    We need to stand up and demand a REAL patient advocate, not a mouthpiece for insurance companies.

  3. Chrissie in Belgium
    Chrissie in Belgium November 8, 2007 at 12:54 am | | Reply

    I agree with you Amy that the words in Dr. Kahn’s speech do NOT “read like the words of a chief advocate for diabetic patients.” I really do appreciate Amy that you take on this battle! As you know, I have had T1 for more than 45 years. It has been a very long, lonely and hard battle. Fighting to stay healthy with so little real understanding. And Terry, I KNOW that diabetes is first of all MY job to take care of. An insulin pump will only provide benefits to those who are willing to invest their own time and effort – but without the pump I failed over and over and over again. For many years I was told that a pump was just another “gimmick”! This was completely wrong. Given the pump AND my hard work, I have been able to achieve much better diabetic values. I am speaking of my own experiences because that is what I know best. This is a hard disease to manage. An advocate for diabetes patients should be encouraging patients who are actively seeking means to control their diabetes. The majority of these patients ARE willing to invest time and effort to correctly use the new tools as they become available.

  4. JasonJayhawk
    JasonJayhawk November 8, 2007 at 12:57 am | | Reply

    As I read the transcript, I thought about the intended audience, and thought that it was to be a “motivational speech” to the people involved in developing diabetes technology. My take-away was that he was warning the industry folk that the insurance companies don’t want to pay for technology that isn’t proven, so the technology companies must develop something that works (both financially and for the patients–specifically, the ones who do not read web blogs or log in to the Internet and understand what to do with the information) or else it won’t survive the marketplace.

    Maybe he’s also saying that Medicare spends $1billion yearly because he thinks the technology companies are getting too much money from diabetics because they’re being overcharged.

    I think we may be reading between the lines too closely about the speech. I can’t see why anyone would tell the “diabetes technology industry” that their very own babies in development aren’t needed in diabetes therapy.

    I do think that he may have been a little too cranky with his comments about clumping Type 1′s and Type 2′s, and that makes me wonder if he (or someone on staff) wrote this speech without thinking about that.

    BTW, the DCCT states that lowering blood glucose lowers complications only in Type 1 diabetics. I believe there was a study done with Type 2′s to see if glucose monitoring improved control in one of this year’s issues of Diabetes Technology (journal), and the result was that testing 0 time and 1 time per day was that there was no significant difference in the final result.

    I hate it when Type 1′s get clumped with Type 2′s, don’t you?

  5. Bennet
    Bennet November 8, 2007 at 4:14 am | | Reply

    I read it too.

    He wrote it. I don’t know why he can’t see what he says.

    Terry, I know I am responsible for my kids’ care and responsible for teaching them to care for them selfs. Why should our care options be limited because others choose not to take care of themselves?

    Managing two kids with type 1 is a wee bit of work. I am happy for advances that can improve our quality of life and free time for the other two kids.

    Quality isn’t from gadgets, as much as it is a function of keeping poorly informed know – it – alls from getting in the way of what we need to do every day. This paper will add fuel to the ignorance fire. I can hear it now “the ADA says you test too much don’t need pumps and should be taking cheap pills. Your unproven toys are at fault for our sky high medical costs.”

    Our kids were not allowed to attend school in part because the school used the pumps as a weapon to keep them out. Ignorance has enough sway as it is.

    I think I don’t need support ADA anymore. That or ADA needs one less guy.

    I put more of my comments here:
    http://ydmv.blogspot.com/2007/11/i-dont-know.html

  6. AmyT
    AmyT November 8, 2007 at 5:14 am | | Reply

    Terry,

    This speech seems carefully crafted for ambiguity. If Kahn meant that the missing component is PATIENT EDUCATION to make the technology valuable, why didn’t he just clearly say so?

  7. Amber
    Amber November 8, 2007 at 5:24 am | | Reply

    He certainly doesn’t need your “biased and infammatory reporting” (winkwink) to come off looking like he’s got the hands of some insurance company or other deep inside his pockets. He does that well enough on his own. As a type 1 diabetic, instead of a cure or something that would make my quality of life just slightly more tolerable, all I have to look forward to in the future is an updated kitchen timer to remind me when I need to take my meds…after all, isn’t that what’s REALLY important?

  8. val
    val November 8, 2007 at 5:37 am | | Reply

    Oh, man, I am just so pissed off over this.

    I have a challenge: To everyone who is upset by this, go make an extra charitable donation to something other than the ADA .

    I just send the JDRF a repeat of my annual donation.

  9. Challenge Diabetes
    Challenge Diabetes November 8, 2007 at 5:38 am | | Reply

    Normalcy First – Technology Second

    I saw a family in the office the other day that was using the continuous glucose monitor for their young boy on the insulin pump. They first said they wanted to have the “latest and greatest” diabetes technology available. As the visit progressed, …

  10. CALpumper
    CALpumper November 8, 2007 at 5:41 am | | Reply

    Kudos to you Amy for taking this on.
    As I read through, I felt Dr. Kahn “attacking” T1, then T2, then technology….he was all over the place if you ask me.

    First, I was diagnosed as T1 in the 80s. I have a receipt my mother found….my parents had no insurance. All they knew was I needed insulin, syringes, a glucose monitor and strips. Back then the bill was close to $1000!!!!!!

    Second, my parents immediately began making changes, what food was in the house (other stuff hidden from me for my siblings), talking to all of us about health, what to eat, exercise….

    All I know is until 2004, I was doing shots everyday. I finally went on the pump and thank God I had health insurance then…

    It is disheartening that Dr. Kahn takes the position he does and felt the need to send the email he did to you.

    Amy you have NEVER done a “dis-service” to your readers. Nor have your readers NOT read into your blog (thanks to your much appreciated and well researched links).

    I think we all are in agreement, we do not like this person advocating for ANY PWD!!!

  11. Michelle
    Michelle November 8, 2007 at 5:45 am | | Reply

    he sent similar emails to just about anyone who has questioned him – he’s really trying to cover himself now. I do NOT think this man advocates for my child, absolutely not.

  12. Mandy
    Mandy November 8, 2007 at 5:52 am | | Reply

    I just wanted to ad that it is almost scarier to me, that he doesn’t see the condescending nature of his speech. You would think after sparking such heated discussions among the people he represents, that he would step back and simply look at what he said objectively. That fact that instead, he basically said prove it and quote me/the speech/ really illustrates to me how arrogant and out of touch he seems to be. Just to remind him, Richard Kahn YOU WORK ON BEHALF OF THE ADA – THOSE WHO PROTECT PEOPLE AFFECTED BY DIABETES (NOT THE INSURANCE COMPANIES!)

    Thank You Amy!

  13. Jenny
    Jenny November 8, 2007 at 6:22 am | | Reply

    The ADA is NOT a group that works in the best interests of people with Diabetes. Sometimes I think its name is constructed along names like the American Library Association–their goal is to PROMOTE the increase in diabetes.

    Their dietary recommendations are for high carb diets full of sugar. Their recommended blood sugar targets quoted by doctors and media like gospel were chosen arbitrarily and are high enough to guarantee neuropathy.

    I guess the device manufacturers haven’t paid them enough to get their support.

    Oh, and did I mention that they are currently running a fund raising campaign using a fundraiser that keeps 80% of the take?

  14. Kevin McMahon
    Kevin McMahon November 8, 2007 at 6:26 am | | Reply

    Firstly, let’s assume that everyone on both sides of this discussion is a real human being and that we all care about people with diabetes living lives free of complications. Anyone so involved as to be on a stage talking about diabetes certainly deserves that level of respect for dedicating most of their waking hours over many years to improving diabetes care.

    Amy finally got close to the point on this in her last comment introducing the guess that Patient Education might have something to do with the point of Kahn’s talk. I have seen other passionate patient advocates who were also upset with Kahn’s talk.

    Unfortunately, throwing more generic patient education at the problem doesn’t work either.

    In a recent research study of diabetes research, the conclusion was that the research over the last 20 years has been very poorly done and non-scientific. The draft article can be found here: http://tinyurl.com/324f2v or by contacting me for the pdf.

    Even device studies are usually approached with such an emotional bias by the investigators as to discount their methods and conclusions.

    My take on Kahn’s talk is that we need to stop throwing new gadgets at patients and expect to improve outcomes. We need to stop pushing the notion of simply ‘test more and you’ll do better’. We need to come up with better ways of individualizing care than just inviting the patient to a Tuesday night support/educational class at the hospital (which is incredibly inconvenient for most people).

    At http://ChallengeDiabetes.com, a clinical diabetes blog, we tackle the gap between technology and outcomes almost every day. We have approached this exact issue by combining the expertise of an endocrinologist, a diabetes behavioral psychologist, a device industry manufacturing executive and patient advocate, CDEs, and technologists.

    Our conclusion: it takes more than just a new device, a new website or a new book targeting the patient who is already tuned into intensive management. The diabetes challenge is to address a far wider spectrum than the readers of this blog. Further, I believe that Dr. Kahn understood exactly who he was talking to and that was a group of technology zealots who don’t always consider the average patient. In order for diabetes technologists to be relevant going forward, Dr. Kahn’s speech put the industry and its cadre of quasi-independent researchers on notice that biased and poorly done research cannot be tolerated any longer.

    After all, who suffers when the diabetes industry (including physicians) get in the habit of handing out yet another new gadget without a proven process to ensure that patients and their providers know how to translate the new technology into improved outcomes?

    We people with diabetes and the millions to come deserve better than what industry has delivered so far. We could welcome Dr. Kahn’s challenge to raise the bar and support his view by holding industry and its translational research teams accountable. Or, we can dismiss it and accept the status quo.

  15. Ed
    Ed November 8, 2007 at 6:28 am | | Reply

    Amy,

    Although I am not a fan of the ADA I can not fully support you or Dr. Kahn in this one. Dr. Kahn is not unwavering in his support of diabetes advances but those of us who are on high-tech insulin delivery device have much tighter control than people who are taking no medicine at all. I believe what he said in a somewhat condencending way is that rather than think the next technological advancement will be the savior we to get those people with poor control a better/ easier/ more efficent way to control their diseases. After we take care of that then the technological advances will make an impact on a larger audience.

    Do I want an artificial pancrease like yesterday? You bet. But at this time I’d rather see a cost-effective way to provide insulin treatments to the 1,000s of people in this country without healthcare. In the end they will live longer, healthier lives and the burden on the healthcare system will be less. I think that ultimatley was the point of his speech.

  16. sarah
    sarah November 8, 2007 at 6:54 am | | Reply

    As a former speechwriter for the presidents of three Fortune 50 companies and a whole lot of senior level government/polictians, I read Kahn’s speech with two “eyes”: a)a diabetic who achieves tight control (current a1c of 5.1%) by NOT FOLLOWING the ADA’s ridiculous “guidelines” and b)speechwriter who knows the tricks of the trade after 30+ years of experience.

    The man is a miserable excuse for a scientist and his letter to you is reprehensible. The more I see of the ADA the more I realize that diabetics need to start a revolt against their so-called spokespersons.

    Sarah

  17. Clinton Cooper
    Clinton Cooper November 8, 2007 at 7:10 am | | Reply

    Thank you Amy for your intelligent analysis! I hope you replied to Mr. Kahn with your comments. He seems to have no clue about how Type 1 and Type 2 diabetics manage their disease. I lose more trust in the ADA every day it seems.

    Clinton

  18. Scott
    Scott November 8, 2007 at 7:17 am | | Reply

    Amy, I agree with Jenny’s comment that the ADA is NOT an organization which has ever spoken for us, the Diabetes Community. The ADA is strictly a group of doctors speaking on behalf of doctors, not patients. Also, the dietary recommendations of the ADA are sadly out-of-date, and in many cases, not applicable to children with type 1 diabetes and seem to be following the USDA guidelines rather than sound medical advice.

    As for Dr. Kahn’s speech, while it may not be what everyone was looking for, akin to universal coverage of the next, more expensive diabetes technology to come down the pike, I think his point may have been missed by some people hoping to hear another speech with more of the same: control, control, control and its all the patients’ fault, not a fault in treatment protocol, in spite of the many flaws in that lofty theory which frankly, fails abysmally in practice.

    I would call attention to another quote from Dr. Kahn, this one from the the Congressionally-appointed Diabetes Working Group report published in 1999 (“Conquering Diabetes: A Strategic Plan for the 21st Century”), which Kahn was the chief author and editor:

    “Genetic engineering of the insulin molecule and new methods of delivery have improved insulin therapy, but in essence, the treatment for Type 1 diabetes has changed little since insulin was discovered.”

    The bigger question is whether this statement is wrong? I would argue that its absolutely correct. Don’t punish the messenger just because you don’t like what he said.

  19. JudyK
    JudyK November 8, 2007 at 7:25 am | | Reply

    Thanks, Amy, for interpreting what this speech says. It was very hard to determine who he was an advocate for—other than insurance companies! Insurance companies do not need any help in denying coverage to diabetics! I fought for 3 diabetes education classes 6 years ago. They were and still are expensive classes but in my city the only place for any intelligent education! One endo can not see all of the diabetics in town and GP doctors don’t always have a clue about T2′s. (The endo sees T1′s and has no time left for T2′s.) I am just now getting a portion of my test strips covered by insurance—and after the ADA supports less testing or less payments for testing, I expect I will be back to seeing test strips not covered by insurance!! They don’t cover A1c testing either so a diabetic could go for some time without knowing he/she is a diabetic if he/she can not afford to pay for tests! Please, Mr. Kahn, don’t help insurance companies save the money I pay in premiums for their CEO’s—–take my granny’s advice and just don’t say anything at all if you aren’t going to help us!!

  20. Becky
    Becky November 8, 2007 at 7:38 am | | Reply

    Hi Amy,
    As a mom that goes to sleep every night wondering if her 9 year old is going to wake up the next day (drastic – I know – but that is a true risk), there is nothing more that I would love than a CGMS. I want one so bad I drool when I think about them. But, my insurance does not see them as medically necessary, so no CGMS.

    Here is why I think this little piece of new technology should be used for Type 1′s:

    You can see patterns and spikes that you never knew where there. That 12:45 am spike to 350…my Pump (wait, that is just more technology) can cover that, that 3:00 pm get off the bus low, wow – I never knew that was happening…People can see what the bs does every 5 minutes and then adjust their other technology based on that.

    Sleep – IF an alarm went off when my child (or when she is a grown-up) went low, I could treat the on-coming low before it hits her…less missed school, less missed work, less hospital visits, less glucagon used, less, less, less…

    Ah, driving…any parents nemesis…getting an alarm when you are driving if your bs is going down hill, grab a carb and keep going…hhhmmm, what would that lead to less of? accidents, insurance rates, traffic violations, possible deaths of the Type 1 and others, less, less, less…

    What about Mr Muscle Man, who was arrested for being drunk but was low…if he would have heard the alarm, he could have gone to the candy counter and gotten something, instead, he ended up in jail!

    Speaking of less, A1C’s dropping by 2 full points with a CGMS??? What, less complications, less heart disease, less kidney failure, less amputations, less, less, less…

    So, for those who don’t think new technology is worth the $, just think of how much less you would have with a CGMS…and don’t even get me started on the pump…

  21. Erin
    Erin November 8, 2007 at 8:13 am | | Reply

    I think Kevin McMahon’s interpretation is right on the money. It’s easy to get worked up over the bad interpretation of Kahn’s remarks, but this point is absolutely true: throwing more technology at type 2 diabetics is not going to make their lives better. They have to understand the way this disease works, and they can only do this with urging from their doctors and diabetes educators (assuming they see them in the first place!) and those professionals can only provide their type 2 patients with good information if they’ve gotten it in the first place. *That* is what Dr. Kahn is referring to with suggestion of more randomized studies, etc. He’s suggesting more doctor education as well as more and better patient education.

    I did not read his comments as applying to type 1s at all. The ADA does not advocate for type 1 diabetics. I hate being lumped with type 2s, but I can bear the burden of educating people around me about the difference. We are only ~5% of the diabetic population, after all.

  22. Sara M
    Sara M November 8, 2007 at 8:19 am | | Reply

    I’ve lived with this overly challenging condition for 43 years and am alive because I’ve been persistant and agressive with my care and control – I’ve fired many doctors because they were patrician in their treatment of my disease, blaming me, the non-compliant, for everything and resistant to change. This is terrorism at its root – a real lack of imagination in terms of dealing with real people and their real experiences. I went through four doctors before finding one who “believed” in the pump – my control was apparently too good – why bother? I paid for my first blodd testing kit out of my own pocket the minute they came out. Both these tools revolutionized my life – who is this Kahn (or is it CON) fellow anyway to claim little has changed in the way we treat this disease. I’m angry like most others who learn about this. I’m contacting every single person I know and asking them NEVER to give to the ADA again, instead give to JDRF.

    Keep up the very very good work AMY! Thank YOU!

  23. Bernard Farrell
    Bernard Farrell November 8, 2007 at 8:27 am | | Reply

    Amy

    First of all, thank you for posting a pointer to the speech itself. Because I looked on Dr. Kahn’s two defunct blogs and couldn’t find it on either one.

    It’s hard to express my feelings about what he said.

    As a person with Type 1 who works really hard to try and maintain a semblance of control, I understand the benefit of these devices. Without them I don’t believe I’d stand any chance of attaining the level of control that the ADA itself is pushing as the standard for diabetes care.

    As an advocate who worked for YEARS to get adequate insurance coverage for people in Massachusetts, I know how bad the insurance industry is at paying for maintenance of severe chronic diseases like diabetes.

    And I think that’s where an organization like ADA should be focusing its efforts. Teach insurance companies that helping people to avoid problems is much more effective, for both costs and quality of life, than paying for the complications after they’ve happened.

    Thanks Amy for starting the discussion.

  24. Melitta
    Melitta November 8, 2007 at 8:31 am | | Reply

    Erin et al, Type 1 (autoimmune) diabetes includes rapid-onset Type 1 (5 to 10% of the total diabetic population) and slow-onset Type 1 (10 to 15% of the total diabetic population). That means Type 1 autoimmune diabetes is about 15 to 25% of the total diabetic population. This information has been known for MANY years, since the detection of insulin antibodies. Time to throw away some tired myths.

  25. Bennet
    Bennet November 8, 2007 at 8:53 am | | Reply

    I wonder if Richard has ever hear of Google? Here’s a sample for Google Scholar
    (http://scholar.google.com/scholar?q=Insulin+pumps+pediatric+&hl=en&lr=)
    Maybe he can work this into his next dog an pony show?

    Insulin pumps in pediatric routine care improve long-term metabolic control without increasing the risk of hypoglycemia
    http://www.blackwell-synergy.com/doi/abs/10.1111/j.1399-543X.2006.00145.x

    Benefits of continuous subcutaneous insulin infusion in children with type 1 diabetes
    http://www.jpeds.com/article/PIIS0022347603005791/abstract

    Insulin pump therapy in pediatrics: a therapeutic alternative to safely lower HbA1c levels across all age groups
    http://www.blackwell-synergy.com/doi/abs/10.1034/j.1399-5448.2002.30103.x

    Persistence of Benefits of Continuous Subcutaneous Insulin Infusion in Very Young Children With Type 1 Diabetes: A Follow-up Report
    http://pediatrics.aappublications.org/cgi/content/abstract/114/6/1601

  26. Anne
    Anne November 8, 2007 at 8:54 am | | Reply

    Some thoughts I have had in relation to this discussion:

    1) When I was first diagnosed in 1988, the ADA was the organization I turned to for support. I met penpals through the Diabetes Forecast magazine and even volunteered for them as a high school student. I since decided that the JDRF was the true advocacy organization for type 1 diabetes; type 2 diabetics will also benefit from the advocacy that they have been doing with Congress this year. (Become a JDRF advocate at http://takeaction.jdrf.org/) Also, JDRF is truly interested in finding a cure for T1 one way or another, or improving health with the “artificial pancreas.” (I disagree with another commenter that this would not be a revolutionary change in T1 care.)

    2) I am fortunate to have a health plan with excellent coverage for diabetes supplies. But I would also agree with Kahn in his criticism of the diabetes industry for the costs of their products, in particular blood glucose test strips. After so many years, I can hardly believe that it is still necessary to keep the prices high on test strips. I just checked at Walgreens.com and prices are >$1 per strip!! This is outrageous — when I was buying test strips in the late 90′s they were actually about $0.70 per strip. I would have more understanding towards emerging technologies initially, but not for long. I can just imagine the board rooms of executives drooling over the epidemic of type 2′s ready to buy their products.

    [My secret conspiracy theory is that a non-invasive glucose meter will never be invented because it would be hard to incorporate disposable parts (aside from the fact that it's tough from a technological point of view). Perhaps this needs to be a publicly funded project...]

    3) I disagree with Kahn’s notion that these technologies are adopted just because they work. The conclusion from the study that showed that type 2 diabetics don’t benefit much from self-monitoring may not be that they should stop, but perhaps be more educated in reading the results. Do a pubmed search on any of these technologies and you will see plenty of articles describing their effects on outcomes such as A1c and complications. Here’s one to look up: Rubina A. et al (2004)
    Continuous glucose monitoring in children with type 1 diabetes: before and after insulin pump therapy. Pediatric Diabetes 5 (1), 10–15. It shows an improvement in A1c and reduction in postprandial glucose after 3 months of pump therapy in kids. There are *plenty* more!

  27. Dave
    Dave November 8, 2007 at 9:06 am | | Reply

    Where you ask what he meant, well, he meant what he said. I understand that the ADA is killing us with their dietary recommendations, but I don’t see that he his comments are negative. He is saying that there needs to be long-term studies to verify that the current treatment platform actually works.

    I did daily monitoring when I was intially diagnosed. I never saw any variation in blood sugar, because of the diet changes I made. I was getting sleepy after eating the “wrong” things, but my blood sugar remained stable. What the heck. At close to $100 a month for a sufficent amount of supplies, this seemed like a waste of money, so I no longer monitor at all.

    We really do need to separate out Type 1 and Type 2 diabetes. They are different diseases with different causes. When Type 2′s start using insulin, is it because the diseases are being lumped into one? What works for a Type 1 doesn’t necessarily work for Type 2s.

    What he is saying is that research needs to be conducted, and that it hasn’t been.

  28. Justin
    Justin November 8, 2007 at 9:16 am | | Reply

    The overriding concern for me is that it is hard to discern just what in the world Kahn is trying to say and I consider myself to be a fairly intelligent person who can usually understand even the most flowery academic rhetoric. Khan’s speech seems more like a stream-of-consciousness exercise written on the airplane on the flight over than anything designed to make a point.

    His response to your coverage was also a missed opportunity to clarify himself despite his obvious concern about being misrepresented. I am left having to make the assumption that Khan is more concerned about the opinions of his colleagues than of the community he supposedly represents.

  29. Randy
    Randy November 8, 2007 at 9:48 am | | Reply

    I don’t think technology, or its continued development is the culprit here. The information that the technology provides needs to be used…. nothing can be managed that isn’t measured, and that’s the problem. The folks that don’t want to make any effort to learn, manage, and make the necessary changes in their lifestyles are the ones who will saddle the system beyond its limits. Granted, there is a lot of apathy and lack of knowledge in primary care circles, and this needs to change before the patients will ever change. Heh, maybe all of us type 1s should just decide to secede from Diabetes – give ourselves a new name like “Pancreatic Insulinimmuno Failure” or something like that!

  30. Jenny
    Jenny November 8, 2007 at 9:49 am | | Reply

    One last point.

    The idea that tools like CGMS can’t help people with Type 2, too, is dangerously wrong.

    After 10-15 years of living with the rotten care and very high A1cs most doctors think are “just fine” for people with Type 2, many people with Type 2 are walking around with blood sugars that would send a Type 1 to the emergency room.

    They have fastings in the 200s. Post meals of 300-400 that only come back down to the 200s.

    They are never told that carbs raise their blood sugar, instead they’re told to eat “healthy grains,” oatmeal, pasta and bananas. And they do.

    Put a CGMS on one of these Type 2s, explain to them the impact of the foods they eat, teach them how to use insulin properly (NOT just giving them generic, massive doses of Lantus with nothing at meal time) and they might just avoid the kidney failure, amputation, and blindness that is otherwise their fate.

    Type 2s have horrible complication rates right now. The ADA and it’s long fight against “tight control” even for people controlling on diet alone is a major reason why.

  31. Felix Kasza
    Felix Kasza November 8, 2007 at 9:52 am | | Reply

    And once again I find myself playing the devil’s advocate, trying to inject some balance into this interesting discussion.

    First, Amy’s interpretation is highly tendentious; cherry-picking quotes does not invalidate Dr. Kahn’s points.

    Second, the mere fact that _some_ have excellent success on a pump does not mean they are statistically significant; I personally know counterexamples.

    Third, at least some of us (and I suspect many) can maintain the same HgbA1c using MDI that we can maintain with a pump. It’s a hassle, but not a major one (adjust Lantus to equivalent of lowest basal rate, simulate basal changes with rapid or regular insulin).

    Fourth, those wonderful studies that a commenter cited as proof of pump superiority either concentrated on a small, non-representative sample (indeed, there are two case reports which aren’t studies at all!), or they compared the pump to older insulin regimens instead of a basal/bolus regimen (MDI).

    In short, I believe that the majority of commenters on this thread _want_ to misunderstand the speech, because it feels nice to be outraged over one’s gored ox.

    As an aside, I have never been an ADA member, my donations go to the JDRF and to insulin-pumpers, and the ADA’s dietary and therapeutic recommendations are risible. I have never heard of Dr. Kahn before, and he doesn’t speak for me.

    Cheers,
    Felix.

  32. Jim
    Jim November 8, 2007 at 10:15 am | | Reply

    It’s evident that Kahn is not used to real world feedback on his manner or his statements.

    Insurance companies influencing the ADA and making sure that people like Kahn are in their hip pocket? Res Ipsa Locitur (“the thing speaks for itself”).

    How dare an actual diabetic clearly demonstrate that the emperor indeed has no clothes….

  33. michael
    michael November 8, 2007 at 10:26 am | | Reply

    friends = insurance companies.
    enemies = diabetics.
    nice.

  34. Sarah
    Sarah November 8, 2007 at 10:57 am | | Reply

    I don’t think T1 was really meant to be included here. We all know the main issue at hand is T2 diabetes. I don’t think anyone inn their right mind would discredit pumps for some T1′s. I for one would be in the hospital every 2 weeks with a hypoglycemic seizure or dead without my pump. Like most T1′s I am too insulin sensitive for standard insulin delivery.

    That said, as stated before, a pump is just a tool, even if it is a necessary one. Some T1′s who use a pump for convenience and not need, put no effort into their care see little improvement.

    If the main focus here is T2 diabetes (which is what the ADA focuses on), then I have to say that Kahn is right. Type 2 diabetics need to make lifestyle changes and/or pop their pills to have normal blood sugars. Simple as that. Testing won’t help the majority of them. I need to test to adjust my insulin dose. Why would a T2 need to test to see that his blood sugar is just above normal range? Or that it is high, tied back to the large amount of carbs he ate for lunch. If he would just follow his meal plan, he wouldn’t be high, and he would need to waste a strip to confirm that.

    I don’t know how many T2′s I hear of that say they go days without testing and they’re fine. If I were to skip ONE day, I’d probably be dead.

    I think it’s obvious that many T1′s either can benefit from or even NEED better technology to live. I am one of those people who would love to have more stable blood sugars and less lows, and the pump has helped me. I have not had a seizure since getting my pump. I am so insulin sensitive that sometimes I only need .35 of a unit to correct a high. Just how can I do that with syringes, unless I crash later? Although I don’t think a CGM is a miracle, it may help me remain more stable. Right now I am riding a horrible rollercoaster that makes life impossible. But I am out of the hospital, thanks to the pump.

    But I don’t think Kahn is addressing Type 1′s. He may be clueless, regardless, but T2 is his focus. And tight control is not enough for T2. They need to lose weight, eat right, exericse, and simply take their meds to do well. And that can be done without any real technology. Most T2′s are “non-compliant” as it is and don’t even bother with testing. If we get them to make changes where it really counts, you have saved the healthcare system a bundle.

    Since I assume that Type 1 has not been on the ADA radar for the past 10 years at least, I suppose I would not be offended if I were an American T1. The ADA should have 2 different chapters for T1 and T2, or call itself the American Type 2 diabetes Association.

    It has to be that, because it is just insane to think that T1′s can survive without technology. If I didn’t test, I’d be in a hypoglycemic coma. That said, it is true that the technology we have to today keeps us alive longer, but Kahn really did have a point when he said that we are virtually still treating T1 the same way, with injected insulin.

    Perhaps after ADA gets all the T2′s to put themselves into “remission” with good lifestyle habits, they can focus on a REAL soultion for T1?

  35. Judy
    Judy November 8, 2007 at 10:57 am | | Reply

    Wow, his response is even more offensive and condesending than his original presentation.

    Both his choice of words and the meaning behind them are clear, no matter how much he tries to spin it with his Montana sized ego.
    Those are not the words of an advocate, they sound more like the words of an insurance adjuster.

    So my question is, why does the ADA have a self proclaimed “non-expert” in the field and someone who is clearly antagonistic toward actual people with diabetes as their spokesperson?

    I would have expected better of the ADA. I would like to see ADA make this right by publicly distancing themselves from him and that type of attitude.

  36. Kate
    Kate November 8, 2007 at 11:51 am | | Reply

    As a medical researcher at a University, I have access to the primary medical literature that many people don’t have available to them. I did a search on CGMS and glucose control…I found articles saying that it works as a useful tool for women with gestational diabetes, preschoolers with diabetes, and type I diabetes in gereral. I wonder how many more studies Dr. Kahn needs before he’s convinced.

    Insulin pumping was a bit more extensive, since the technology has been around for longer. I’m quoting an abstract from one of the articles here:

    Insulin pump therapy is not required for all patients with type 1 diabetes, since intensive treatments produce very similar results in terms of glycated hemoglobin and control of complications over the medium and long terms. However, the pump allows for greater comfort for patients, with less rigid meal schedules and better quality of life.

    Perhaps that is the point. We shouldn’t ask our insurance companies to spend the money for comfort, flexablity, and quality of life…when all he is interested in is gycemic control. Spoken like a true non-diabetic.

    I’m sorry to sound bitter but I read Dr. Khan’s speech and I felt like he was Ebeneezer Scrooge and I was the “surplus population.”

  37. MD
    MD November 8, 2007 at 12:41 pm | | Reply

    I’ve always had my doubts about the ADA. First of all, I once went to volunteer event there and, I kid you not, they served us PIZZA!

    Can you imagine?? Serving a room full of diabetics pizza–at the NYC ADA headquarters.

    I never went back, obviously. Secondly, take a look at the cover of the recent Forecast:

    http://www.diabetes.org/diabetes-forecast.jsp?WTLPromo=HOME_forecast_110107freeissue&vms=247847403674

    A gigantic Bundt cake!

    Whose side are these people on??? What reality are they living in??? Not mine, that’s for sure.

  38. Pearlsa
    Pearlsa November 8, 2007 at 12:54 pm | | Reply

    This is interesting, why should a speech be analyzed as if it was a grade school literature book?

    As a Type 1 diabetic I have never met a doctor who is willing to just throw insulin pumps and CGM at their patients. Patients in 98% case have to work hard to prove to the doctor they are committed to their diabetes management and care.

    Richard Kahn would know this if he had spent some time talking to both doctors and patients before writing his speech.

  39. mcityrk
    mcityrk November 8, 2007 at 1:13 pm | | Reply

    Hi-

    The biggest problem with the good Doctor’s speech was that it was too long, wandered all over the place, and was so ambiguous that even fair minded people could come up with alternate interpretations for almost any statement. That of course means it will be forever parsed to validate whatever argument a speaker or institution makes, whether it be pro technology or pro cost-containment. If a for-profit exec was so inexact in a quarterly conference call, the value of the company would drop 50% overnight-

    mcityrk

  40. Linda B.
    Linda B. November 8, 2007 at 1:14 pm | | Reply

    Does this man even have diabetes, 1 or 2? I was diagnosed at 9 in 1979.
    the onbly training I ever got until my mid 20′s was from the childrens hospital where I was diagnosed.
    I could not get access to the supplies I needed because my family did not have insurance. I got my first meter at 15 and never learned how to use it, there was no one to teach me. Years later after being uncontrolled I do have many complications, eyes, nerves, kidney, etc.
    I know why, no access to what I needed. I had to fight for the pump, fight for a monitor, test strips and everything else I need to have some quality of life.
    For this man to say basically that all these gadgets are irrelevant, he comes across to me as being book smart?? but d-life retareded.
    I also help care for both my inlaws and my husband who are all type 2′s. They know what they need to do, but, no medical professional has ever taken the time to show them what to do with the toools they are given. Not one of my inlaws doctors has sat down an shown them what they could and should do. If you were to ask them how they manage their diabetes care they would not be able to tell you. They and I am serious here, do not know what a carbohydrate is. That is sad. they both are very ill and there diabetes has never been controlled. Lack of education and Ignorence are the big factors here and unfortunatly Mr. Kahns take on this is only going to back up my inlaws when it comes to their care. This guy says stop testing. Well he must know he’s with the ADA, so we are not going to test anymore.
    let him come down here and deal with this anguished family when one of my inlaws passes from complications of this disease. Let him be the one to explain himself to these people who took his word as an expert and are now dying because of it. Don’t think is happening already? I am sure there are plenty of families who are or have gone through this.
    As a side note…. I do not have health insurane. I know what I need to make my life liveable. I have all the numbers and test results from pumping and not pumping, having test strips and not having them, and living with the knowledge that one day something is going to happen, to me. The last time I tested my glucose was olmost two months ago. Not because I don’t want to, but because I do not have the money to buy them. Let’s see, But test strips for 100.00 or get two bottles of insulin for 100.00, what choice would he make???
    Wre as a group who live with our diabetes everyday should band together and ask the ADA questions. how can any of them sleep at night knowing that the statements and philosophies they put out affect millions of people. Mr. Kahn you may be able to leave your so called work at the lab at 5 pm every day, but we pwd’s live this 24/7, with no paid vacations, weekends off or bonuses from Insurance and drug companies for sidling up to them. I hope you are enjoying your brown nose, I can smell it right here in front of my computer.
    Let me pose this question, would you be spouting all this stuff if it was your childs health and well being at risk? Or do these statements not bother you because you don’t have any experience hands on with the day to day of diabetes? People are always so quick to judgement and ideas when they are not dealing with it first hand. The lab may be a good start but everyday life is the true test, have you looked into that?????

  41. Kathy
    Kathy November 8, 2007 at 2:08 pm | | Reply

    Been a T1 since 1983; I actually did an internship at my local ADA office in college. They never have, and never will, speak for T1 diabetics. All they care about is raising more money to spend on more “education”. I was never treated worse in my life than the 6 months I spent in their offices. Kahn is a typical example of the spokespeople they embrace.

    T1s of the world, unite!

    Kathy (araby62 on TuDiabetes)

  42. Paula
    Paula November 8, 2007 at 2:23 pm | | Reply

    I read the entire speech yesterday, and was about to post a lengthy comment. But JasonJayhawk and Kevin McMahon have said much of it already. This wasn’t a speech written for a patient audience, and to try and interpret it in that context is misleading. Dr. Kahn spoke about today’s managed care environment and how we might best focus limited resources to improve patient outcomes based on those realities. Calling him “anti-diabetes-technology” is unfair at best.

    Amy, I’m curious. Has Dr. Jackson (Joslin) given you his opinion on Dr. Kahn’s talk? I’d be curious to know his take, from a clinician’s point of view.

  43. None Given
    None Given November 8, 2007 at 3:56 pm | | Reply

    Sarah said:
    Why would a T2 need to test to see that his blood sugar is just above normal range? Or that it is high, tied back to the large amount of carbs he ate for lunch. If he would just follow his meal plan, he wouldn’t be high, and he would need to waste a strip to confirm that.

    Sarah, If I had followed my meal plan for the last 3 years, I would be on insulin by now and probably be having complications. That meal plan kept my FBG >200mg/dl with maximum doses of 2 meds, you don’t want to know what 225g carb/day did to my after meal readings. Instead, I tested after everything I ate and adjusted my meals to stay under 140mg/dl (it adds up to a lot less carb.) If I go higher than I want I can take a walk instead of doing the dishes, if I know I need to. For 3 years now my A1c has been <6% because I tossed that meal plan and one of the meds
    and tested. A. LOT. And continue to test enough to know when things change.
    The ADA does not speak for me.

  44. Big_Dave_T
    Big_Dave_T November 8, 2007 at 6:15 pm | | Reply

    I went back and read Dr. Kahn’s speech in its entirety. I did see the word “value” prominently featured there, as I speculated in my comment yesterday (darn, I’m good).

    My biggest problem with his speech is that it declares that focusing on value and medical necessity in health care is a relatively new concept. Speaking as someone with 25 years experience seeking payment from insurance companies for physicians services, I can say that insurance companies have NEVER given health care providers blank checks to prescribe and treat patients with the latest methodologies, drugs and technology.

    From time to time, there IS a hue and cry about the cost of health care. I remember hearing from a prominent economist over 20 years ago that this country could not afford to spend the percentage of its gross national product on health care as it was doing then.

    But that percentage continues to rise and this country still does pay the bill one way or another. So Dr. Kahn is offering no new perspective, but is merely resonating the concerns of business and other healthcare payors.

    Not that some of his points aren’t valid, but I do like the headline in your post here. Whom is he speaking for? I still would like to see a patient advocate, like yourself, in a policy-making position with the ADA.

  45. Jim
    Jim November 9, 2007 at 1:24 am | | Reply

    Sarah said:
    Why would a T2 need to test to see that his blood sugar is just above normal range? Or that it is high, tied back to the large amount of carbs he ate for lunch. If he would just follow his meal plan, he wouldn’t be high, and he would need to waste a strip to confirm that.

    ————–
    Individuals react differently to the same foods r.e. blood sugar levels.

    Exactly what “meal plan” would you recommend for an older T2 woman who exercises very little and a younger woman training to run a marathon? Or a business professional who works 8-10 hours per day and exercises 45 min, 3 times per week? Or a mail delivery person who walks all day every day for her job?

    Hopefully you don’t mean the useless plans put out by the ADA, do you?

    Sorry, Sarah, there is no way a T2 can “know” what his/her blood sugar is unless they test, and test often.

    Tight control is the ONLY approach a T2 can reasonably rely upon to avoid the complications that come with diabetes.

    That’s just the reality of it.

  46. camille johnson
    camille johnson November 9, 2007 at 7:20 am | | Reply

    As a T1 since 1982 (25 years) I quickly became convinced that the pharma companies ONLY wanted to “invent” technology that could make them richer and richer. For example, back in 1982, test strips were made of paper and could be cut in half to go twice as far. The companies QUICKLY invented plastic strips that could not be cut. Hmmm. Coincidence? I don’t think so.

    AND the insurance companies ALWAYS lag in accepting new technology so they don’t have to pay for it. I’ve been waiting for a continuous glucose monitor for 20 years (and I’m sure the technology was out there) but it’s only been available for a year or two. Now, the 7-day Dexcom is available but still considered (by my insurance) as experimental. Why? Because, obviously, the 3-day require twice as many replaceable parts (at $125 a shot) as the 7-day. And, is $125 even remotely related to reality? Yes, I want the pharmaceutical companies to make some profit but this is GOUGING and Greed. GREED. GREED!

    Question: Surly, there must be some department in government (paid to protect citizen rights) that looks out for us. And fights for us. If the insurance syndicate and the pharmaceutical syndicate are the sole influence on capital hill, then where are the consumer advocate group?

    For the record, this are my list of things that piss me off about the diabetic industry (read: suppliers and insurance; an unholy alliance if there ever was one):
    1. cost of test strips
    2. non-availability of generic insulin
    3. lag in development/availability of CMG
    4. influence of pharma cos on law/policy
    5. influence of insurance cos on law/policy
    6. lack of influence by T1 diabetic citizens on law/policy

  47. camille johnson
    camille johnson November 9, 2007 at 8:01 am | | Reply

    Another comment:

    It seems that Doctors, Diabetic Educators, et al, are ONLY “educated” by pharmaceutical companies and insurance companies. AND they seem to eat it up, thinking that “now” they know how to treat their patients better. Bah! Humbug!
    Solution: Let’s develop a 5 or 7 point laminated list to distribute to EVERY medical person everywhere. The list would teach them how to question the “reps” that come to visit them on a daily basis. It would teach them to be cynical. It might go something like this:

    To ALL medical personnel:

    QUESTIONS TO ASK YOUR PHARMA REP WHEN THEY VISIT YOU:
    1. How much does this cost the patient (assuming there is no insurance) per day / per month / per year?
    2. Never let the rep. talk like every patient has good insurance, or any insurance at all.
    3. Write their answers down on paper. Make a simple chart so they can see that you understand the real cost.
    4. How many patients (T1? T2?) will WANT this product? Translation: How many patients feel this product will help control their diabetes. No, the pharma cos aren’t the best people to ask but believe me, they’ve done their research and the numbers will astound you (any maybe the rep).
    5. If they don’t have the answers, show them the door and tell them to find the answers and don’t return until they have the answers. Also, tell them you will not be prescribing ANY of their products until they give you answers!
    6. Verify their answers with real Diabetic patients. Use your own patients.

    KEEP THIS LIST TAPED TO YOUR WALL WHERE YOU CAN SEE IT AT ALL TIMES, AND USE IT. DON’T BE INTIMIDATED BY PHARMACEUTICAL COMPANIES.

    The cost to do this, though great, is minimal compared to the potential benefit. And don’t cope out by making it sound ‘nicer’, or sending it out in some throw-away mailing, or worse, a non-read email. It has to be a ‘keeper’. Hard plastic. Colorful. Small enough to fit on a desktop but big enough to see from 6 feet.

  48. Karen
    Karen November 9, 2007 at 9:36 am | | Reply

    Amy…dear Amy…can you tell me the POINT of his e-mail? Does he consider that “Damage Control”? I wonder…after a few days to think about it, if he realizes he just messed up BIG time. In my eyes the e-mail he sent you was WORSE than his speech. What a jerk. I hope he reads this comment b/c he needs to go to the ADA board and read what people are saying about him…NOT GOOD. Sorry Dr.Khan, but if you hear the words “YOUR FIRED” in the next few weeks do not be surprised. But hey…at lesat you don’t have diabetes!

  49. AmyT
    AmyT November 9, 2007 at 11:24 am | | Reply

    Thank you, Karen.
    I did wonder why Dr. Kahn was so defensive, rather than trying to help the community make some sense of his speech.

  50. Sarah
    Sarah November 9, 2007 at 12:57 pm | | Reply

    I DO NOT consider the ADA meal plan appropriate for Type 2 diabetics. But I think any diabetic with half a brain can see that, and would never follow it in the first place. It is a crime that the ADA states that T2 is a progressive disease. Of course it is when you follow the diet they suggest.

    T2 diabetics (in general) should be on low carb, low glycemic, low bad fats, and high fibre diets, which will automatically go a long way to keep their blood sugars stable. They should avoid all junk, processed, high fat, high glycemic, and high carb foods. I personally have never met a T2 not on insulin with severe swings in blood sugar. Most of the time, they stay fairly close to slightly above normal range, unless they eat something they shouldn’t, are stressed, or are ill. For the last two categories at least, it is true that testing is very important.

    The fact is, the *vast majority* of T2′s gain very little from testing overall once they have made the proper lifestyle choices. I’ve read an article stating that one T2 knew to cut out his favorite candy snack after testing his blood sugar only to find it made his blood sugar shoot up. DOH! I mean if some people really ARE that dumb, OK. Give them a tester. But perhaps we should educate people to avoid those high glycemic foods 100% to both prevent and treat T2 diabetes in the first place.

    It’s not that I think T2′s not on insulin should never test (of course not), but it is true that studies have shown that for most T2′s not on insulin, testing makes little difference on a daily basis. The exception to this would be adjusting meds for weight loss, exercise, illness, etc.

    Sure maybe 20% of Type 2′s (including misdiagnosed LADA’s, MODY’s, thin and very active people with genetic insulin resistance, people who take steroids and other meds, those with other medical conditions, etc.)*should* test daily. But the point is that for the T2 diabetes epidemic as a whole, technology is NOT the answer.

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