16 Responses

  1. Joe
    Joe May 20, 2013 at 4:45 am | | Reply

    That Garber person sounds like someone who has never lived with Diabetes or knows of someone with Diabetes that deals with it every day.

  2. Penny
    Penny May 20, 2013 at 5:59 am | | Reply

    “”There is no excuse for high blood glucose in the United States, given the vast array of agents to choose from,” said Garber, who then followed up with, “What undermines our efforts is noncompliance on the part of patients.””

    THAT’s the part that really pisses me off. How the heck are little diabetics – the little T1s of this world – ever supposed to grow up healthy – physically and emotionally – with this kind of stuff being told to their future doctors???

    Have they not listened to the voice of ANY patient – T1 or T2? It’s like they forgot they were dealing with actual people.

  3. Mary Dexter
    Mary Dexter May 20, 2013 at 7:01 am | | Reply

    I was able to download the PDF last week and found page 6 particularly shocking. That’s the page with the 3 columns listing monotherapy (1 pill), dual therapy (2 pills) and triple therapy (3 pills), along with the A1C. A patient is given 3 months to fail on each therapy before progressing to the next therapy and a total of 9 months before starting insulin (3+3+3=9months) . Even in the last column, with an A1c over 9, they must be symptomatic (not defined) before starting insulin.

    I don’t think it’s the patients who are not complying with what Banting and later science have demonstrated. It’s the AACE.

    1. Mary Dexter
      Mary Dexter May 20, 2013 at 6:55 pm | | Reply

      Page 6 is the page pictured.
      I had an A1C of 13.3 and was losing weight, when I was dx as Type 2, told to eat less and put on Metformin. After a tantrum, I was given an endo, dx as LADA and prescribed insulin. The stories I hear from others with LADA differ only in the number of months or years before someone finally listened. I am alive because I refused to comply ( and every few years I must fight so my prescription isn’t cancelled). They are the ones who are noncompliant, not us.

  4. StephenS
    StephenS May 20, 2013 at 7:12 am | | Reply

    Wil, thanks for the detailed information. To say I’m shocked is an understatement.

    There are, in fact, several reasons for high glucose (and low glucose) in the USA today. Not the least of which is Dr. Garber and the AACE. I love my endocrinologist, but if she ever starts handing me that crap I’ll find a new one.

    If their policy is “Scare the patient” or “Show how much the AACE doesn’t know about living day to day, year to year with diabetes”, they’ve nailed it.

  5. Tom Clark
    Tom Clark May 20, 2013 at 10:26 am | | Reply

    This reminds me of an article I read a few years ago about an endocrinologist (actually a diabetologist) who after 25 years of treating type 1′s married a woman with type 1 diabetes. After 6 weeks of living with the woman and seeing first hand what PWD deal with on a daily basis he was blown away. He said no amount of book knowledge or clinical experience prepares a physician for what it’s like to live with the disease.

    1. Wil
      Wil May 20, 2013 at 5:20 pm | | Reply

      What a great idea! We should make all endo marry one of us! Anybody got a list of hot female endos… Oh wait. I’m already married. Never mind. But really, what about endo camp? What do you all think of endos being required to spend a week or two a year in the trenches WITH us 24-7. They could even get CMEs….

  6. Bob Fenton
    Bob Fenton May 20, 2013 at 3:18 pm | | Reply

    I summary, I am surprised at what is not included. This would be exercise (covered in a blog on April 24 by Tom Ross) and allowing patients to start without medications or using medications for bringing prediabetes and diabetes under excellent management and then weaning off medications as lifestyle goals are met. No mention is made of working at the prediabetes level of lifestyle changes to prevent the onset of type 2 diabetes. Also missing is the option for those patients wanting off oral medications and onto the full insulin therapy. Apparently this is not allowed under the algorithm. For these reasons, I feel strongly that the algorithm is shortsighted and presents a defeatist attitude for patients.

    As a patient, I am very concerned about how they feel that diabetes is progressive and they offer no hope of people preventing this. Thanks Will, for pointing out they also missed depression.

  7. Scott E
    Scott E May 20, 2013 at 4:06 pm | | Reply

    The “no excuse” part of this line is an equal-opportunity offender. So-called “compliance” does not respect government boundaries; everyone has their struggles, internal negotiations, lapses in judgment, and indulgences. I’ve dealt with those types before, and I’ve learned to brush them off as ignorant and unrealistic.

    But what really ticks me off is the second part, where he says “…in the United States, given the vast array of agents to choose from.” This is not the United States that I know of. My United States keeps the latest technology and medicine from us due to the bloated regulatory environment, while our friends across the pond get to enjoy much more sophisticated tools that help them to live better than we can. The pumps, meters, and CGMs we have are archaic compared to some of the other stuff out there. My Diabetes Blog Week “Petition” talks of everything that is wrong with this process.

    For this so-called expert to makes such a statement without a clue about the place or people he speaks of is infuriating.

    1. Amy A
      Amy A May 24, 2013 at 10:51 am | | Reply

      Scott – Very salient points. It is frustrating to know that we seem to get second class technology because regulators go too far in the US.

    2. Tanya
      Tanya September 19, 2013 at 11:35 am | | Reply

      I agree with you. We can’t get a pump because, “Regular insulin is cheap and can work just fine without a pump. If you want to pay $2000/month, we can get you one.” Really? Why am I paying for insurance again? Oh yeah- In case my diabetic ends up needing to be treated in the hospital because we can’t afford a pump. What a twisted snowball!

  8. Kim
    Kim May 21, 2013 at 1:09 pm | | Reply

    Is anyone else disappointed with the phrase “suffering from diabetes..”? Seems a bit condescending to me.

    And no excuse for High blood glucose? I have often thought that as part of their training, endos should follow a person with Type 1 through two typical days. On the first day, the endo could make all bolus, eating, and exercise decisions, The person with Type 1 would make all of the decisions the following day, to see how their results compare. It would most likely be quite an eye opening experience. I feel fortunate that my endo has Type 1, and consequently does not play the blame game.

  9. Amy A
    Amy A May 24, 2013 at 11:00 am | | Reply

    I am an analyst by trade, I completely understand the algorithm – and even that word choice – BUT as it is with most things in life, there is more to the story than data points and empirical evidence.

    Garber seems to forget that ‘non-compliance’ is not a matter of willpower, or intelligence, or even obstinance. What he terms as ‘non-compliant’ I term as life. It is when life and this diabetes algorithm collide that we have to apply artistic license. I am sure he considers that non-compliance.

    To counter effect life’s impact on my disease, I apply the art to the science. The art of forgiving myself for slacking on testing, the art of fudging a bolus because I am not sure about my carb counts, the art of knowing I cannot do it all and being ok with that.

    So you can graph and chart and color code your little heart out. And if that helps you manage D, then great. But if you only do it sometimes, or don’t at all, that does not make you non-compliant. That just means that the algorithm cannot possible cover all situations that we PWDs encounter.

  10. Evan N. Ferguson
    Evan N. Ferguson May 25, 2013 at 8:25 am | | Reply

    The American Association of Clinical Endocrinologists (AACE) is the largest association of clinical endocrinologists in the world, with a membership of more than 6,500 endocrinologists in the United States and abroad. The majority of AACE members are certified in endocrinology, diabetes and metabolism and concentrate on the treatment of patients with endocrine and metabolic disorders including diabetes, thyroid disorders, osteoporosis, growth hormone deficiency, cholesterol disorders, hypertension and obesity. The AACE Annual Scientific and Clinical Congress provides a forum for continuing education, and discussion of innovations and cutting-edge research in endocrinology. For more information on the Association, visit our site at .

  11. Chris Casey
    Chris Casey May 30, 2013 at 3:15 am | | Reply

    I’d like to give those types of doctors a shot of humalog and see how well they do with a reaction,

  12. Kris
    Kris February 24, 2014 at 2:12 am | | Reply

    I am not sure why folks are bashing the AACE so much, the ADA which receives money from many food companies and as some say have carbohydrate recommendations too high is not immune to legitimate criticism from dr. bernstein and others.

    Insulin should probably be used earlier, but its not a cure-all, attacking the root issues of diabetes is key, the older medications such as su and their related glinides although prandin is unrelated but has a similar action, are accused of “forcing the pancreas to make insulin like beating a horse too much and eventually it doesn’t work as effectively”, yes if your car is reverse getting more men and having them push the card harder might do the job, or for a better analogy pushing the car over snow rather than removing the snow.

    Also, there is evidence that SUs/and Glinides can cause beta cell apoptosis, once the beta cell dies out, there is little to no chance of getting it back. I agree insulin should probably be higher in the algorithm, but insulin has its issue mainly not addressing the root causes, causing hypos, weight gain in many patients (though not all), and the issue of injections and possibly antibodies? This is why the aace rightly placed it along glinides and SUs in a sense, although wrongly in a sense that folks may need it sooner.

    I applaud the aace for bringing us attention to other agents such as welchol and br quick release although those have not been used extensively and are probably not covered by most insurances or have a lot of hassle, in addition they have modest effects in lowering blood sugar, but do not have appear to have the sever side effects such as macular edema, vomiting, of other drugs.

    The tzds are listed with caution, yes its true that many drugs are associated with big pharma, but the author neglects that with the generics mainly consist of metformin and the su/glinides because they are older medications and the su/glinides tend to fail and not address the issues. Insulin is also associate with big pharma with the exception of the relion brands.

    Cycloset and Welchol are not big pharma drugs, they are small pharma, the glinides are generic, most of the blood pressure medications are generic in all the various classes, actos is generic, and avandia will be soon, acarbose is generic, most statins are generic as well as fibrates, niacin, fish oils,etc

    I agree that patient bashing is unacceptable especially since the disease is rather a symptom than a cause as most people think of it since lada and MODY and other various factors cause high blood glucose rather than the simple diet and exercise factor. Since doctors change opinions and new information comes out and changes such as with avandia, patient skepticism should be encouraged to a degree.

    This is legitimate criticism, and it seems aace just throw out a lot of different meds, but criticism seems overblown.

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