Controversies in Care in Pediatric Endocrinology The Great Debates

摘要

Three different pairs of diabetes experts debated 3 controversial questions. The first question was, is primary prevention of type 1 diabetes possible? Dr. Desmond Schatz (University of Florida) presented a convincing argument as to why this is not only possible but also necessary since, without prevention, there will never be a cure. One of his first slides elucidated the fact that type 1 diabetes prevention has all the requirements for a primary prevention study. It has a favorable cost-benefit ratio to individuals and society, there are effective methods for identifying those eligible for intervention, and the disease is detected early enough to intervene. Dr. Schatz pointed out that we cannot afford to "do nothing" to prevent diabetes, since the incidence of type 1 diabetes has reached epidemic numbers, and there has been no recent improvement in early mortality, nor a reduction in acute complications. The limited evidence of improvement in long-term outcome, which is the potential benefit of improved glycemic control, is only reaching a minority of affected children. He discussed that along the continuum of genetic predisposition to frank diabetes, the former would be a very opportune time to intervene. There is strong evidence that besides a genetic predisposition, there is also likely the presence of an environmental trigger(s). To support this claim, he stated that the incidence of diabetes is rising, in 90% of cases there is no family history of diabetes, there is enormous country-to-country variation, and there are animal studies that concur with the environmental trigger theory. He made the argument that primary prevention might be possible by showing early data from the Trial to Prevent Diabetes in Genetically At-Risk Relatives (TRIGR) study. More recent preliminary data suggest that only 2% of the children in the intervention group developed diabetes compared with 6.5% of the children in the control group. This pilot led to the International TRIGR Trial (of which his opponent is the United States Principal Investigator), currently in its fifth year. Also, The Environmental Determinants of Dia- betes in the Young (TEDDY) study will provide valuable data on environmental triggers. Some potential strategies for prevention include removal of incriminating environmental factors, redirecting the immune system, and utilizing agents that decrease intestinal permeability.