William V. Tamborlane, MD, earned his medical degree from Georgetown University in 1972 and currently works in the department of pediatrics at Yale University School of Medicine and is director of the Yale Children’s Diabetes Program. He holds and has held several leadership positions within the American Diabetes Association. He is a member of several professional societies and editorial boards and has authored more than 450 articles in the areas of diabetes management, treatment, and research. His research efforts include the invention of insulin pump therapy in the 1970s and current work on the development of an artificial pancreas or continuous blood glucose monitoring system. Dr. Tamborlane has received numerous awards for his work, including the Juvenile Diabetes Research Foundation’s Mary Tyler Moore and S. Robert Levine, MD Excellence in Clinical Research Award and the foundation’s CT Hall of Merit.
Diabetes1: How did you get involved in medicine, and particularly in pediatric endocrinology?
Dr. Tamborlane: I realized I was never going to play for the Yankees so I needed a Plan B. I eventually got into medicine and thought about going into internal medicine. But, I decided I liked working with kids more than adults. I didn’t think I would be a good surgeon and I enjoyed endocrine disorders. I got involved with treatment protocols for diabetes ketoacidosis. I had the opportunity to work with Dr. Robert Sherwin [currently the CNH Long Professor of Medicine at Yale University School of Medicine in New Haven and the director of the Yale Center for Clinical Investigation and the Diabetes Endocrinology Research Center and widely recognized as a key diabetes researcher]. I stayed on at Yale and carried out some of the pioneering studies on insulin pump treatment in the late 70s. That was a really good start and I have been involved in the care of children with type 1 diabetes ever since. We used pump treatment to see the effects of lowering blood sugar, which we hadn’t been able to do effectively before about 1979. When we did our first pump studies, it was pretty primitive. That started to turn around with pump treatment, A1C measurements, and home glucose meters. That opened up the door to intensive management of diabetes. Our interest was the benefits and risks of intensive management and using pumps as a way to achieve better control. I participated in research on lowering glucose and human growth hormone. Early on, we recognized that once you treat, the patient gets used to lower values and won’t recognize the signs of hypoglycemia. That remains the major obstacle to successful treatment – most successful patients have trouble recognizing when their blood sugars are getting low and taking corrective action before they pass out. With severe hypoglycemia, being severely impaired is the major obstacle to successful management. The most difficult aspect is that when a patient is trying hard and succeeding in many ways in getting their sugars down, that makes them doubly vulnerable to severe hypoglycemia. They lose some of their defenses compared with people who are not as well controlled. That’s why I am so excited about the introduction of the continuous blood glucose monitoring systems. We can see what blood sugar is doing every 1 to 5 minutes. It can set off alarms if there is a problem. We can see what happens after eating certain foods. There is a lot of work in that area currently, including most recently the first study of children in a 36-hour inpatient setting where a computer ran the pump automatically based on continuous glucose monitoring data.
Diabetes1: How do you balance your research work and clinical care?
Dr. Tamborlane: We have built a clinical care team that is primarily directed by nurse practitioners. We take great pride that we have the best type 1 diabetes program in the country. We have achieved a standard of control that compares favorably with other similar facilities. We have three full-time nurse practitioners devoted to taking care of kids. We also have doctors, part-time nurse practitioners, and dietitians but it really is a nurse-practitioner-directed practice. That frees up much of my time for research and administrative responsibilities but seeing patients is still the most enjoyable part of the week.
Diabetes1: What effect is the growing obesity epidemic having on type 1 diabetes?
Dr. Tamborlane: The theory, the accelerator hypothesis, is that the obesity epidemic will actually bring on diabetes sooner in type 1 patients. It will make beta cells secrete more insulin, resulting in faster burnout or an aggravated autoimmune response. Obesity may be increasing the prevalence of type 1 diabetes but I think it’s a modest effect.
Diabetes1: How have pediatric patients and their families changed over the years?
Dr. Tamborlane: I’ve been pleasantly surprised at how diligently a lot of our kids work at controlling their diabetes. It’s much more than I would have expected when I first started. I think it has a lot to do with continuing support. In my early days, I despaired that teens would fight tests and shots. I couldn’t figure out how a 15-year-old would care enough about his health now so that he will stay healthier at 40. Most teenagers just want to get a date, make the starting baseball team or pass an exam. A trick that has had a tremendous impact is the ability to perform hemoglobin A1C tests in the clinic at the time of a visit with a very small capillary sample. The test can be conducted and we can get results right as we’re talking to the patient. We see patients every three months so the test gives us their quarterly grade. Kids understand grades. It’s really concrete reinforcement that they can get their arms around. It has had a great effect. As far as how we approach parents, when I started, the big emphasis was on independence for the kids. I think that was the dumbest idea I’ve ever seen. It only occurred to me when my own kids were teenagers. Independence and responsibility for teenagers meant doing nothing. The key is maintaining a healthy partnership between the parents and the kids. We work toward that, letting parents take part of it. Most parents would take on diabetes in place of their kids if they could so we encourage them to take on some of the management. They can keep track of trends in blood sugar, what they’re doing over time. The real challenge with pediatric patients is that they are always outgrowing their insulin but kids are not very good at looking for trends over time.
Diabetes1: How do you feel about the success of diabetes research?
Dr. Tamborlane: I see it as half full, half empty. We’ve learned a lot about the etiology of diabetes. Many distinguished scientists are looking at the autoimmune process. The half-empty part is how much of that is translated into better care for patients. That’s the area to which we devote most of our efforts. If you make a list of advances in treatment in the last 25 years, it’s not a long list. There is blood glucose monitoring, new insulin analog, pump therapy – there are a relatively small number of new tools that we have to deal with the problems of managing type 1 diabetes. But, if you’re able to support a program with clinicians who can spend a lot of time with patients, it’s amazing what patients can do. Looking back, when A1C measuring was first introduced, the majority of our teenagers were in the 10 to 11 percent range. Today, A1C values are down to the mid 7s. Another study we published last year surveyed patients over the age of 10 who have had diabetes for at least three years. In a review of their recent eye exams, none had evidence of retinopathy at their last exam. We are beating diabetes. We can do that with the tools we have. But, it’s a painful process and we have to beat it every day.
Diabetes1: How do you feel about the level of support your research receives from government and the general public? What could be done and improved in the field of juvenile diabetes research?
Dr. Tamborlane: There is never enough money. I think in a lot of ways, researchers are always complaining that there is never enough support but type 1 diabetes does relatively well. That’s partially because parents of children with diabetes who helped form the Juvenile Diabetes Research Foundation (JDRF) are very aggressive in fundraising. The JDRF supports research. They are also very good lobbyists for federal funding. Type 1 diabetes has done fairly well but we can always do more with better funding. The encouraging thing is that the JDRF which has always been tremendously focused on finding a cure for diabetes has broadened its scope. More recently, with advances in therapy and the artificial pancreas, there is a greater appreciation for the need for research for better treatment until we get to a cure – creating a bridge to a cure. Sensor studies are in the works, looking at how we can test the accuracy and effectiveness of continuous glucose monitoring devices as they come online. The first few were not very effective. We are now one of a group of centers working on an artificial pancreas.
Diabetes1: How do you see the future of diabetes research? Will stem cell research play a part in this future?
Dr. Tamborlane: The “cure” for diabetes may take one of two avenues. One is biological or cellular and involves replacing beta cells. The other is a mechanical cure or approach to beta cell replacement. I think that much more effort has gone into the cellular side, including pancreas transplants and converting stem cells into islets or beta cells that can be transplanted. These are all important areas of research. Mechanical solutions were kind of a moot point until we had continuous glucose monitoring which is just beginning to get off the ground. Several centers, including our own at Yale, are very much into this area of research. In the future, I would like the artificial pancreas thing to move along faster. Research is very different than in the old days when it comes to regulatory hurdles. It’s important that closed loop artificial pancreas systems get careful scrutiny but to get studies moving has taken an awfully long time. Perhaps there is some overkill in the regulatory hurdle. I think some of those hurdles are being broken down so I’m very hopeful that we can move this along and get at least some early versions of automatic glucose control into patients outside of the hospital setting.
Diabetes1: What part of your work do you find the most rewarding?
Dr. Tamborlane: Like Lou Gehrig said on his last day at Yankee Stadium, I always felt I was the luckiest person around. I enjoy everything I do, even the administration part. However, the greatest privilege is to work with patients and their families. If we can make diabetes management understandable to our patients and their parents it feels very good.