Dr. Joseph Wolfsdorf
Dr. Joseph Wolfsdorf is the Associate Chief and Clinical Director of the Division of Endocrinology and Director of the Diabetes Program at Boston Children’s Hospital. Educated at the University of Witwatersrand in Johannesburg, South Africa, Dr. Wolfsdorf’s career has largely been devoted to clinical care, teaching, and clinical research. He is a longtime supporter and advocate of JDRF and our Outreach Program, and joined the New England Chapter’s Board of Directors in 2012.
Dr. Wolfsdorf shared his perspectives on current diabetes care:
What is the top piece of advice you give newly diagnosed individuals and families as they learn to cope with and manage type 1 diabetes (T1D)?
The diagnosis of diabetes in a child is a crisis for the family. Parents are often shocked, grieve the loss of their healthy child, and feel utterly overwhelmed. At this time of vulnerability, they are expected to learn how to take care of a child with diabetes in a very short period of time. I emphasize that it is important not to try to learn everything—because this is an impossible task. Their primary objective in the early days should be to learn the basic “survival” skills while we (members of the multidisciplinary diabetes care team) will support them and insure that their child is safe. In other words, I tell them to “take it slow” and allow time to adjust and heal. They need to gain confidence that “I can do this” before we burden them with a vast amount of information on all the details of diabetes self-care. I also make a point of informing patients and parents that they should know that diabetes mellitus is a serious disease, but that the long-term results of current therapy will undoubtedly be better than the outcomes of diabetes care in the past. There can be no doubt that the prospects for a young person with T1D are far better than they used to be. Numerous studies have confirmed that modern therapy has decreased complication rates in young people with diabetes.
What is the biggest challenge patients with T1D face?
It is impossible to generalize because I take care of patients whose ages range from less than 1 to more than 20. The specific challenges (for patient and parents) are different at each developmental stage of childhood, adolescence and young adulthood. Most individuals get used to insulin injections and fingerpicks, which they come to view as a nuisance and a hassle, but not especially painful or uncomfortable. The hazard of hypoglycemia (day and night) is always present. For some, real fear of hypoglycemia, especially during the night, is a major challenge. For others, loss of the ability to spontaneously eat meals and snacks without thinking about how much carbohydrate is in the food and how much insulin is needed to cover the food is very challenging. For many adolescents, feeling different from one’s peers and having to perform all the tasks required to maintain good blood glucose control while being a “normal teenager” is especially challenging.
Until a cure is found, what type of treatments or new technologies do you think will make the most impact on lessening the burden of the day-to-day management of T1D?
In my view, advances in diabetes treatment have increased the burden of care as compared with treatment methods used before 1993, when the Diabetes Control and Complications Trial (DCCT) conclusively showed that any sustained reduction in hemoglobin A1c levels lowers the risk of diabetes complications. This led to the recommendation that most youth with diabetes should receive intensive therapy. In other words, more effort devoted to diabetes self-care every day does result in better glycemic control. This will assure individuals better long-term health outcomes. To reduce the burden, technologic innovations that are robust, reliable and automated are what patients with diabetes need. The person with diabetes must be able to rely on the device to accurately measure blood glucose concentrations and deliver the optimal amount of insulin (or suspend insulin delivery in the event blood glucose levels are trending downward and hypoglycemia is imminent). For example, if glucose sensors were available that were accurate and after calibration did not require finger prick blood glucose measurements with a meter for management decisions, more children and adolescents would be willing to tolerate the additional discomfort associated with insertion and having another device attached to one’s body.
What do you find to be the most exciting or promising areas of T1D research today?
Despite the above comments, I believe that device manufacturers deserve kudos for having made considerable progress over the past two decades. Modern smart pumps are amazing devices. The principal problem is not the pump, but the infusion cannula (the tiny plastic needle situated under the skin), which so easily occludes, kinks or becomes displaced, leading to lack of insulin delivery and its serious consequences—hyperglycemia and ketosis. Glucose sensors improve every year and I am confident they will continue to get better. Currently available glucose meters can provide accurate blood glucose values within a few seconds on a blood sample about the size of the head of a pin. That is truly phenomenal! My dream is that scientists will discover how to grow beta cells (the specific cell in the pancreas that measures blood glucose concentration and produces insulin) in limitless quantities and learn how to protect them from the aberrant immune attack that destroys healthy beta cells in the first place. I view technologic innovations (i.e., devices, sensors, “bionic or artificial” pancreas, etc.) as an intermediate step on the road to a real cure, which will involve replacement of beta cells. I am confident that this day is not too far away. Unfortunately, for the person living with diabetes and for their loved ones, tomorrow is too long to wait.