Last year, the 20th anniversary of the Barbara Davis Center foundation provided an opportunity for reflection. The Center has grown from a Pediatric Clinic caring for 400 children to a complex institution that provides clinical care to over 5,000 patients and leads the nation in childhood diabetes research. More than 1,000 of the patients come from outside Colorado, places as remote as South Africa, Turkey, Ukraine, Israel, England or Chile.
The quality of clinical care available to our patients has improved dramatically under the leadership of Dr. Peter Chase, Clinical Director of the Center for the past twenty years. Only one in four of newly diagnosed children in Colorado are hospitalized at onset, while in other parts of the U.S. and abroad nearly all of such children spend a few days in a hospital at diagnosis. After diagnosis, the rates of re-hospitalization and ER visits for diabetic ketoacidosis are 50% lower among our patients, compared to those living in other areas with academic centers.
The Barbara Davis Center provides a comprehensive clinical care delivered by a team of eleven doctors, eleven diabetes nurse educators, four dieticians and two social workers, with an on-site Eye Clinic and continuity care into adulthood through the Young Adult Clinic. About a quarter of our patients have no or little health insurance, but receive usual state-of the-art care. The routine care includes cutting-edge devices and test rarely available in other centers. It extends after hours to an unlimited phone/fax/e-mail consulting between visits and a 24/7 physician advice hot line. Year 2001 has witnessed the beginning of Internet-BDC that is being built to increase access to and efficiency of our clinical services. In 1980, Barbara Davis stated at the Center’s dedication ceremony that the Children’s Diabetes Foundation “is based on love and caring and that strong base will help us to continue to give, to share, to build and to learn”. As it was 20 years ago, the unique Clinical Program of the BDC can be sustained only through the generosity of many supporters of the Foundation.
The Pediatric Clinic, headed by Dr. Georgeanna Klingensmith, continues to assist over 2,700 children with diabetes. Every year, the Clinic provides initial treatment and education to nearly 200 families with newly diagnosed child and 70-100 new families that come to the Center for further help, after initiation of treatment elsewhere. We also teach other doctors, nurses, dieticians, and psycho-social care providers. The 6th biennial Keystone Conference in July 2000 was attended by over 300 participants from all over the U.S. Clinic staff travels regularly to remote areas of Colorado and neighboring states to provide outreach clinics and educational programs. Annually, we distribute over 20,000 copies of the educational textbook “Understanding Insulin Dependent Diabetes” by Dr. Peter Chase, now in its 9th edition.
The pediatric insulin pump program is growing dramatically with over 4,000 pump patient visits since 1997. With clinical research into Glucowatch, MiniMed and Spectrx continuous glucose monitoring systems spearheaded by Dr. Chase over the past two years, the Clinic is now opening a new frontier in the standards of care for children with diabetes.
The Young Adult Clinic, headed by Dr. Satish Garg, offers a unique model of continuity of care for diabetic children who outgrew the Pediatric Clinic and otherwise would be tossed into the deep unforgiving waters of adult health care. Many of the 1,400 young adults seen at the BDC have no health insurance and inadequate primary health care as they go through difficult years of college, first employment, and starting families. The Young Adult Clinic staff has been instrumental in bringing to this patient population both structure and the newest advances in diabetes care, such as Humalog and other insulin analogues, insulin pumps, Glucowatch, 24-hour ambulatory blood pressure monitoring, and most recently the electron beam computed tomography for early detection of coronary heart disease.
The Ophthalmology (Eye) Clinic, directed by Dr. William Jackson and opened in 1996, provides in-house comprehensive retinal care for diabetic children and adults alike. Technological advances in digital imaging of the back of the eyes without the need of dilating the pupils has made screening for diabetic eye disease easy and widespread. While sophisticated laser therapy is available at the Eye Clinic, with preventive measures it may become needed less frequently in the future.
The biggest change in the Clinical Program in the past five years has been addition of several important Clinical Studies. The Diabetes Prevention Trial (DPT-1) has been the first large placebo-controlled trial to try to prevent type 1 diabetes in high-risk relatives. Dr. Peter Chase has led the Colorado center, one of nine centers nationwide, to screen and enroll a fourth of the trial participants. Anyone who has lived with the disease will agree that it is better to prevent diabetes than to deal with the shots, blood sugar testing, diet, fear of hypoglycemia and ketoacidosis and eye, kidney, and heart diseases that so frequently occur in long –standing diabetes. Dr. Peter Gottlieb has recently initiated two trails in adults and children with newly diagnosed diabetes aiming at inducing full and lasting remission without need of insulin shots.
These trials and DPT-1 have become possible due to an explosion of knowledge about the causes and progression of childhood diabetes. Dr. Marian Rewers is directing one of the studies that have been instrumental in learning the causes and risks of diabetes. The Diabetes Autoimmunity Study in the Young (DAISY) has screened for diabetes genes over 24,000 newborns from families where nobody has diabetes as well as over 1,500 young relatives of people with the disease. Those at risk have been followed for up to eight years to define the reasons why some children progress to diabetes while others are protected. Certain genetic backgrounds have been found to cause diabetes in up to 50% of children, while routine childhood immunizations, viral infections, and cow’s milk consumption have not been associated with diabetes. The project that involves also as investigators Drs. George Eisenbarth and Georgeanna Klingensmith, has been recently refunded by the National Institutes of Health for another five years. Drs. Rewers and Eisenbarth teamed up also to study the occurrence of celiac disease (“wheat allergy”) in patient with type 1 diabetes. It turns out that 10% of the patients, including up to 30% of those with certain genes develop celiac disease. In 1998, based on these findings, the BDC Clinics have begun to screen routinely all patients for celiac disease and other associated conditions, e.g., autoimmune thyroid and adrenal diseases.
Dr. Satish Garg has evaluated in his studies a number of new insulins, novel ways to deliver insulin, blood sugar measuring devices and drugs that reduce the risk of long-term complication. In 2000, Drs. Rewers and Grag have initiated a study of early detection of heart disease in 1,400 adult patients with type 1 diabetes and their spouses/partners. The study, funded by the National Heart, Lung , and Blood Institute is pioneering the use of electron beam computed tomography in detecting microscopical calcification of coronary arteries. This powerful tool will be used to better define the genetic and metabolic causes of heart disease that is the underlying cause of death in nearly 80% of patients with childhood diabetes.
Drs. Klingensmith, Rewers, and Eisenbarth have been funded by the Centers for Disease Control to register all children with diabetes in Colorado, Wyoming, New Mexico, and Arizona. This five-year long project will determine the characteristics of all patients that lived in the region in 2001 and those of all newly diagnosed children starting in 2002. The registry will help to understand if the incidence of childhood diabetes is increasing, and if so why. In addition, the patterns of access to care, its quality, and early complications will be determined.
An increasing number of children is being diagnosed with diabetes that resembles more that often seen in adults (type 2, non-insulin dependent). Drs. Georgeanna Klingensmith and Phil Zeitler will study this new epidemic in a series of studies designed to define the magnitude of the problem as well as the best ways to prevent and treat this type of childhood diabetes.
In other studies, Dr. Philip Walravens has recently evaluated metformin (Glucophage) and inhaled insulin as adjunct treatments for children with diabetes. Dr. William Jackson participates in a number of studies aiming at prevention of eye disease, Drs. Eisenbarth and Gottlieb study the Addison’s disease and cellular markers in patients with type 1 diabetes, and Drs. Chase and Garg pioneer clinical applications of a series of continuous glucose monitoring systems. Nearly every month a new clinical study that benefits both the participating patients and the progress of science is added to the Clinical Program at the BDC. The Translational Research Unit, supported by Children’s Diabetes Foundation at Denver and headed by Drs. Rewers and Gottlieb puts special emphasis on translating the newest research discoveries into routine clinical care at the Center.