Good News About Diabetes Care

CLINICAL DIABETES
VOL. 17 NO. 3 1999

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EDITORIAL

Irl B. Hirsch, MD, Editor

As an internal medicine resident in the mid-1980s, I recall seeing large numbers of patients with either type 1 or type 2 diabetes receiving a single morning injection of insulin. Those receiving their care from endocrinologists were often, although not always, advised to administer three injections per day, but this was a small minority of patients.

It was also quite clear that, for the most part, the glycemic control of the majority of patients with diabetes was quite poor, by anyone's standards. Double-digit HbA_1c levels were common. Control was usually considered adequate if there were no symptoms of uncontrolled hyperglycemia. Since this was considered both the academic and community standard, this philosophy was mimicked in the conventional therapy group of the Diabetes Control and Complications Trial (DCCT).¹ Control was only intensified in that study if there were symptoms of uncontrolled diabetes or if HbA_1c levels rose above 13%. Only at this point, both in the study and during my training, did we really take notice of the hyperglycemia.

The reasons for this are well-documented. Both in medical school and later during my residency training, it was explained that "hypoglycemia is worse than running a bit sweet" or "we really don't know if improved control makes a difference." Of course, with the publication of the DCCT in 1993¹ and the United Kingdom Prospective Diabetes Study (UKPDS) last year,² those arguments are no longer valid. In addition to the introduction of new drugs in the 1990s, we have also learned how to use insulin better to minimize the risk of severe hypoglycemia.

Surveys of diabetes care from the 1980s certainly reflect my experience. For example, a late-1989 survey conducted by the National Institute of Diabetes and Digestive and Kidney Diseases (published in 1993) reported that only 5% of primary care physicians recommended three or more injections per day for their patients with type 1 diabetes.³ Much more concerning from a variety of reports was the infrequency of referral for dilated eye exams, assessment for albuminuria, and routine foot inspections for individuals with either type 1 or type 2 diabetes.

It is with this background that the more recent surveys of physicians' behaviors are more encouraging. In the Third National Health and Nutrition Examination Survey conducted from 1988 to 1994 and published earlier this year, the mean HbA_1c for individuals treated with insulin was 8.3% compared to 8.0% for those treated with oral agents.⁴ These levels are much lower than what I saw 15 years ago. I consider this a small but important step in the right direction.

Another encouraging piece of news is that insulin regimens are becoming more flexible and are based more on physiology. One 1998 survey noted that only 7% of patients with type 1 diabetes receive a single daily injection of insulin, and 53% inject twice daily, while 40% receive at least three shots per day.⁵ Similar changes have occurred for people with type 2 diabetes who use insulin. Sixty-seven percent administer their insulin twice daily, while 12% administer their insulin three or more times each day.⁵ These data are quite different from my observations 15 years ago.

What are some of the reasons for this good news? Improved medical school and residency training programs cannot accept any credit,⁶ although I suspect this situation will also improve with time. Although there are no guarantees that diabetes care will continue to improve in the future, I believe it will because it is receiving attention like never before.

For better or worse, much of this is related to financial issues. From 1 April 1993 to 30 March 1994, the Wall Street Journal published 69 articles that mentioned diabetes. From 1 April 1998 to 30 March 1999, the same newspaper mentioned diabetes 174 times. Enough is happening in our treatment of diabetes that it was mentioned more than 2.5 times more often this past year than it was 5 years ago in one of the most important financial newspapers in the world. This is all happening because we now have so many more options for treatments: insulins, oral agents, blood glucose monitoring devices, and so forth. Between the new importance of diabetes on Wall Street and our new tools to manage our patients, diabetes is much more visible than it was in the past.

For the most part, this is all good news. Of course, our new treatment options will cost us more, at least in the short run. Enter a new concept: "disease management programs," which can assist us in providing cost-effective care for complicated diseases, such as diabetes and asthma. The success of these programs remains to be seen.⁷

A larger concern is that we should not be too quick to congratulate ourselves. The mean HbA_1c levels for patients receiving insulin or oral agents are still above targets, and non-Hispanic black women and Mexican-American men are particularly susceptible to diabetes-related complications.⁴ By no means have we, as providers for patients with diabetes, reached our targets. Still, I am encouraged that we are doing a better job and hope that until there is a cure for all kinds of diabetes, we never accept anything less than all patients meeting their treatment goals.

REFERENCES

¹The DCCT Research Group: The effect of intensive treatment of diabetes on the long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977-86, 1993.

²U.K. Prospective Diabetes Study (UKPDS) Group: Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352:837-53, 1998.

³Tuttleman M, Lipsett L, Harris MI: Attitudes and behaviors of primary care physicians regarding tight control of blood glucose in IDDM patients. Diabetes Care 16:765-72, 1993.

⁴Harris MI, Eastman RC, Cowie CC, Flegal KM, Eberhardt MS: Racial and ethnic differences in glycemic control of adults with type 2 diabetes. Diabetes Care 22:403-408, 1999.

⁵1998 Roper Starch Survey of the U.S. Diabetes Market. Unpublished data, used with permission.

⁶Hirsch IB: Diabetes education (for doctors). Clinical Diabetes 17:50-51, 1999.

⁷Bodenheimer T: Disease management-promises and pitfalls. N Engl J Med 340:1202-1205, 1999.

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