Control, Complications, Confidence: The Regenstrief Conference on the Risks and Benefits of Intensive Management in NIDDM

Many adult diabetic patients and their doctors, it seems, minimize the importance of non-insulin dependent diabetes mellitus (NIDDM), seeing it as “just a touch of sugar” and not confronting the real damage it can inflict. But even those of us who, as diabetologists, have spent a good part of our careers struggling with the worst diabetes has to offer—the ugly foot ulcers and the mutilating amputations, the enervating nephrotic syndrome and renal failure, the seemingly endless constipation and diarrhea and gastroparesis, the ravages of galloping proliferative retinopathy—have until now directed our therapies more to the control of acute, present symptoms than to chronic, future complications.

The concept that tight control might prevent the microangiopathic, neuropathic, and macrovascular complications in both insulin-dependent and non–insulin-dependent patients certainly isn't new; Elliott Joslin, among others, preached this message more than half a century ago. Our greater focus on present rather than future outcomes therefore can't be attributed to a lack of ideas about what to do. What we've lacked is the confidence to implement a tight control strategy in the face of all odds. Although we've been willing to give tight control the benefit of the doubt, the odds against achieving the last measure of tight control were, and still are, heavy. In patients with NIDDM, the seeming intractability of obesity; the frequent failure of sulfonylureas, if not primary then secondary; the serious toxicity, and ultimate removal from the market, of phenformin; and, ultimately, the stresses of insulin therapy, including the indignities and …