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This is an interesting but sad statement:

Type 1 Diabetes in Adults: Growing Management Crunch Forecast

By Bruce Jancin
Elsevier Global Medical News
Breaking News

KEYSTONE, Colo. (EGMN) – The number of adults with type 1 diabetes is quietly and steadily climbing – and the American health care system is utterly unprepared to handle their needs.

So asserts Dr. Irl B. Hirsch, professor of medicine and holder of the Diabetes Treatment and Teaching Chair at the University of Washington, Seattle.

“The folks at [the Centers for Medicare and Medicaid Services] are not ready for the impact of type 1 diabetes in the Medicare age group over the next 10 years. I’ll say it publicly: They are clueless,” Dr. Hirsch said at a conference on the management of diabetes in youth, sponsored by the University of Colorado at Denver and the Children’s Diabetes Foundation at Denver.

Adult type 1 diabetes poses huge public health issues, in part because of physician workforce constraints. This is a disease that will of necessity be managed primarily by nonendocrinologists, he said.

The projected number of internal medicine–trained clinical endocrinologists is nowhere close to meeting the growing demand for management of type 1 diabetes in adults. Primary care physicians do not have the skill set or time to provide state-of-the-art diabetes management. Few geriatricians are trained in type 1 diabetes. So the task, by default, will fall upon the shoulders of the midlevel providers – nurse practitioners, physician assistants, diabetes educators, and registered dieticians, he predicted. And he’s just fine with that.

“The DCCT [Diabetes Control and Complications Trial] was done by midlevel practitioners. That’s how we run our clinic, too,” he said. “The midlevels are going to be in charge, there’s no doubt in my mind. And this will work.”

The incidence of type 1 diabetes is doubling roughly every 2 decades in developed nations. The rising population of U.S. adults with type 1 diabetes has two sources: a steady increase in patients with new-onset type 1 disease arising in their 30s, 40s, and beyond, and improved longevity of patients with childhood-onset type 1 diabetes.

“In our clinic, the biggest surprise for our internal medicine residents and our endocrine fellows is how many of our patients are diagnosed after the age of 20. It’s a lot. I can’t say exactly, but it’s easily over a quarter of our type 1 patients who are diagnosed after age 20,” said Dr. Hirsch.

The age record at the Seattle clinic is held by a patient who presented at age 92 with newly diagnosed, autoantibody-positive type 1 diabetes and a history of Graves disease and vitiligo.

“We [don’t] really understand the epidemiology and demographics of type 1 diabetes in adults .... But now with the better treatments, having patients live for 50 years with type 1 diabetes is routine. It’s not a big deal anymore,” he said.

A large new research grant from the Leona M. and Harry B. Helmsley Charitable Trust is going to provide badly needed data on type 1 diabetes in adults.

“You’ll be hearing a lot more about this project soon. We’re in the midst of planning a very large registry of patients called the Type 1 Diabetes Exchange, where we hope eventually to have data on 100,000 individuals,” said Dr. Hirsch.

With regard to new-onset type 1 diabetes in adults, Dr. Hirsch highlighted a well-documented Italian study that demonstrated that the incidence in Northern Italians aged 30-49 years was similar to that in 15- to 30-year-olds. Among males there were twin peaks in incidence: one at age 10-14, and a second at age 45-49. The trend in females was similar except that the second peak wasn’t as high as the first (Diabetes Care 2005;28:2,613-9).

Dr. Hirsch said that by a very conservative estimate there are 1.1 million American adults with type 1 diabetes of either the classic type or latent autoimmune diabetes of adults (LADA), a group whose absolute need for exogenous insulin is somewhere between that of classic childhood-onset type 1 diabetes and adult type 2 disease. By a recent estimate, LADA accounts for 2%-12% of all cases of diabetes (J. Clin. Endocrinol. Metab. 2009;94:4,635-44).

He does not include in his tally of adults with type 1 diabetes the very large group with what is often called “type 1.5” disease: that is, phenotypic type 2 disease with autoantibody positivity. Type 1.5 diabetes is roughly two- to threefold more common than classic childhood-onset type 1 diabetes, but there is not as yet agreement on how to classify it. He excludes them from the type 1 diabetes category because type 1.5 patients have major problems with obesity and metabolic syndrome, which are not issues in managing type 1 disease or LADA.

The forecast is that in the year 2019 there will be roughly 3,200 internal medicine–trained adult endocrinologists. Assuming that close to half of them are not seeing any new patients because they are fully booked, or are not taking new diabetic patients because the reimbursement is paltry compared with the effort required in state-of-the-art disease management, or due to pressing research or administrative responsibilities, that would work out nationwide to 636 type 1 diabetic patients per practicing endocrinologist. That’s just not realistic, Dr. Hirsch said.

Approaching the manpower issue from another angle, Dr. Hirsch said his recent informal, nonscientific survey of adult endocrinologists in St. Louis, Seattle, Los Angeles, and Chicago suggests type 1 diabetes typically accounted for 20% of their patient load. Again, that doesn’t come close to meeting demand.

“No matter how one does the math, type 1 diabetes in adults will by necessity be cared for by the primary care physicians,” he said.

But that’s not realistic, either, the way primary care medicine is practiced at present, he quickly added. “In current internal medicine residency training, we put little or no emphasis on insulin therapy in general, let alone type 1 diabetes. And current primary care systems lack an infrastructure for insulin therapy, let alone pumps, sensors, and the like,” according to Dr. Hirsch.

And then there are the brutal time constraints imposed on primary care practice, he continued, citing a recent survey of 2,500 family physicians which showed that patients with well-controlled diabetes were on average allocated just two 10-minute office visits per year for their chronic disease.

Through the Helmsley Trust project, diabetes researchers expect to generate much more specific figures as to the actual time primary care physicians spend in managing type 1 diabetes in adults, he added.

Dr. Hirsch declared having no financial conflicts regarding his presentation.


Tags: LADA, T1

Views: 1851

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Thanks for posting. Is sad & frightening.
This confirms the vibe I was getting from my NP about the "newness" of the rising number of Type 1 adult cases, and related insulin dependent types... "rare" appears to becoming less so, and the medical community is being taken by surprise.

Thank God Tudiabetes exists-- I think I would have been a nervous wreck if I didn't have access to a resource with so many smart and knowleadgable patients!
Hi Caprifoglio: I would actually disagree--adult onset Type 1 diabetes has always been more prevalent than childhood onset Type 1 (I have a 1950s diabetes book that documents that and in 1934 Dr. Elliott Joslin noted that the incidence of diabetes in lean individuals [Type 1] was relatively constant in each decade of life, but that diabetes in the obese was related to older age) but the problem is that usually people with adult onset Type 1 are misdiagnosed as having Type 2 (an altogether different disease). So I would say that the only thing that is "new" about adult onset T1 is that more people are getting correctly diagnosed. Gradually, within the last decade or so, the medical community has started to acknowledge the prevalence of adult onset Type 1, although too many are still misdiagnosed.

And you are so right, we are so lucky to have TuDiabetes, to share and support!
Some of the confusion has come about because of the confusion in medical practice in the diagnosis of diabetes. There was adult and juvenile onset diabetes, where adult onset included both what we now know is T1 and T2. Then there was insulin depdendent and non-insulin dependent diabetes, IDDM could be both T1 and T2. And this diagnosis confusion continues today, you are T1 if you arrive in the ER in DKA, otherwise you are T2 until proven otherwise. And why bother proving anything? There are stories of T1s who have spent 30 years with their charts marked T2 because nobody bothered to diagnose them. Even today, many doctors won't bother to diagnose you as a T1, after all if you are T1, it gets really bad and you end up in the ER, then it is obvious.

Personally, I'd rather use a simple blood test to diagnose my condition rather than depending upon a near death experience. But who am I to question medical practice?
But near death experience is so fun! Just kidding, naturally. :)
Hi Brian/bsc: And you can have the near-death experience and STILL be diagnosed as having Type 2! That was what happened to me. Near death, hospitalized, DKA, then taken off of insulin and discharged from the hospital (my blood sugar was only about 350 mg/dl at discharge). But within a week my diagnosis was changed to Type 1 and I was on MDI, due to the fact that I am a pit bull in human form. However, that was 15 years ago, and I do think that there have been improvements since. I find it shocking that in Irl Hirsch's article he says that most adult onset T1s will be treated by non-endos. That is horrifying to me. I see an endo, and can't imagine being treated by a GP.

I thought I was the only one with this story. Turns out it is way more common than anything. When I was Diagnosed I was pretty much textbook DKA (I lost twenty pounds off my already slender frame; urinating every five seconds by the gallon; and pretty much bed ridden with a mouth so dry that my tongue glued itself to the roof)with a 400+ BG level.
They just discharged me two days later with Metformin and Glipzide. And because I was still making insulin I was labeled a type 2.
Well, I had to fight for an antibody test and...SURPRISE...I had GAD antibodies and my PCP still wanted to treat me like a type two because I was exercising good control. I was having good control because, for the past several months, my diet had been so restricted.
Well, as of three days ago an endo FINALLY diagnosed me LADA and put me on insulin and I feel so much better now.
The medical community should really fix itself when it comes to this. I imagine it is MORE common than type 2 because they just diagnose you type 2 on general principle.
Thankfully I found this site or else I might have wound up back in the hospital. I had to fight for insulin. My docs REFUSED to put me on it.
They basically want your pancreas to go kerplunk before they do anything.

Congrats on getting your correct diagnosis and treatment, Tommy...now you might have to change your screen name!

Yeah, I totally do now (lol).
I made this name when I thought my first doc knew what she was doing.
For the last three days, since I've been on Lantus, my BG's have been beautiful and I'm eating more healthy. I heart insulin. :0)

Congratulations on a job well done! I was lucky. My primary diagnosed me as T2 but a wonderful nurse/CDE saw the 425 on my first finger stick, realized how out of it I was and sent me to the ER. She also told me in passing that I would not only be using Lantus but also Humalog before meals. That was over my head at the time but she clearly was making at least a tentative T1 diagnosis. Of course, nurses aren't allowed to diagnose so it took a couple more days and a second ER visit for everyone to figure it out.

That makes sense -- now that you mention it, I think I read something in discussions here that mentioned something about that, and that there isn't much data about T1 adults in general... I'll have to see if I can find it...
I think of all the pesticides being used.

Just the other day I had a helicopter attack by my house mosquito spraying with numerous small children out playing. ummmmm

Then I read the other day that DEET used in bug spray repellent is getting into the ground water after people take showers and then it is ingested via the ground water.

With this growing in frequency something is going on Melitta




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