Nearly 26 million people are living with diabetes in the United States today.1 Between 1990 and 2010, the number of people diagnosed with diabetes more than tripled 2; that’s only within the past 20 years…how about within the past 40 years?
The number of people diagnosed with diabetes in 2010 was over 13 times that of people diagnosed with diabetes in 1960!2 The health and economic burden of diabetes is on the rise. The Centers for Disease Control and Prevention estimate that 1 in 3 individuals could have diabetes by 20503. In 2007 alone, the total estimated diabetes cost in the US was $174 billion1.
Aside from the prevalence rate, the risk for death among people with diabetes is about twice that of people of similar age but without diabetes1. These staggering statistics are not only an indication that people are not adopting healthy lifestyles but also a testament to how poorly the disease is being managed. The suboptimal management of diabetes is attributed to both physician and patient factors, including poor adherence to evidence-based guidelines4, poor compliance to treatment regimens5, and insufficient patient education6,7.
Physician Adherence to Guidelines
Despite the availability of multiple diabetes self-management guidelines, studies show that implementation of guidelines—by both primary care professionals (PCPs) and specialists—is low4,8. A 2011 survey by Beaser et al reported that only 36% of PCPs routinely apply evidence-based diabetes guidelines to their practice, while the same was true for a mere 18% of diabetes specialists.8
If diabetes guidelines are designed to provide a road map for disease management, why aren’t more physicians using them on a regular basis? Reasons vary. Some healthcare professionals (HCPs) cite inadequate coordination with other providers as a barrier to implementing guidelines; others believe that the lack of easily retrievable electronic health information presents a hurdle to tracking patients with diabetes.4 Importantly, there are HCPs who prefer to rely on their own knowledge and clinical experience rather than guidelines when making treatment decisions; the survey by Beaser and colleagues revealed that 62% of diabetes specialists depend solely on personal judgment when managing patients with diabetes, versus 21% of PCPs who do the same.8
Patient Adherence to Treatment Regimens
Perhaps the following quote captures nonadherence to treatment best: “The best medications in the world can’t help those who don’t take them as prescribed.” Less than 50% of diabetic patients achieve HbA1C levels at the recommended targets, suggesting that nonadherence to therapy plays a big role in the suboptimal glycemic control.5
Between 2007 and 2009, 58% of patients with diabetes were treated with oral medication only and 12% were treated with insulin only.1 Patients' reluctance to initiate and intensify insulin therapy is attributed to multiple factors, including fear of side effects; phobia of needles; and inconvenience and complexity of treatment regimens.9 In addition, patients" misconception that insulin use is reserved just for serious cases may also hinder adherence.9
Nevertheless, the updated 2013 American Diabetes Association guidelines stress the importance of timely initiation of insulin, recommending its use—with or without additional agents—in newly diagnosed type 2 diabetic patients.10
The recent emergence of novel formulations and methods of insulin delivery, such as insulin pens, may help to lessen anxiety over needles and simplify treatment regimens.9 However, optimal patient adherence will depend largely on adequately educating patients about the benefits of newer insulin formulations and delivery systems.9
Patient education cannot be overemphasized in diabetes care. It is imperative that patients become sufficiently knowledgeable in managing their weight, fitness, and blood sugar and that they properly adhere to treatment regimens.6 Unfortunately, patient education is lacking, especially in the primary care setting where over 80% of diabetes care is delivered.6 Studies show that the use of certified diabetes educators (CDEs) by PCPs is rare, primarily due to reduced access.8 However, even when PCPs do have access to CDEs, only a minority of patients are referred.8 Results from the 2012 National Diabetes Education Practice Survey showed that only 16% of respondents estimated that at least 75% of their patients had begun diabetes self-management education (DSME) within 6 months of their diagnosis.7 In addition, many patients in 2012 did not complete the full 10 hours of DSME, even though it was covered by Medicare and most insurance carriers during the first year of diagnosis.7
Where Are We Headed?
Undoubtedly, we’ve come a long way in diabetes care. The introduction of numerous oral agents and advances in insulin delivery systems have multiplied treatment options for patients with diabetes. However, gaps in care still exist, leaving plenty of room for improvement. Thus far, we have approached diabetes management from a predominantly medical standpoint—concentrating our efforts on treating the disease rather than preventing it; is it time to change our approach?11 After all, no amount of novel agents and technologies will reduce the growing prevalence of diabetes if we continue to neglect the root of the problem. To nip diabetes in the bud, emphasis on lifestyle changes, including diet and exercise, should take center stage.11
- Centers for Disease Control and Prevention (CDC). National diabetes fact sheet: national estimates and general
information on diabetes and prediabetes in the United States, 2011. http://www.cdc.gov/diabetes/pubs/factsheet11.htm.
Accessed October 23, 2013.
- CDC’s Division of Diabetes Translation. Long-term trends in diagnosed diabetes. October 2011.
http://www.cdc.gov/diabetes/statistics/slides/long_term_trends.pdf. Accessed October 23, 2013.
- CDC. Number of Americans with diabetes projected to double or triple by 2050. October 2010.
http://www.cdc.gov/media/pressrel/2010/r101022.html. Accessed October 23, 2013.
- Appiah B, Hong Y, Ory MG, et al. Challenges and opportunities for implementing diabetes self-management guidelines.
J Am Board Fam Med. 2013;26:90-92.
- Bailey CJ, Kodack M. Patient adherence to medication requirements for therapy of type 2 diabetes. Int J Clin Pract. 2011;65(3):314-322.
- Tomky D. Diabetes education: looking through the kaleidoscope. Clin Ther. 2013;35:734-739.
- Martin AL, Warren JP, Lipman RD. The landscape for diabetes education: results of the 2012 AADE National Diabetes
Education Practice Survey. Diabetes Educ. 2013;39:614-622.
- Beaser RS, Okeke E, Neighbours J, Brown J, Ronk K, Wolyniec WW. Coordinated primary and specialty care for type 2 diabetes mellitus, guidelines, and systems: an educational needs assessment. Endocr Pract. 2011;17:880-890.
- Campbell RK. Recommendations for improving adherence to type 2 diabetes mellitus therapy—focus on optimizing insulin-based therapy. Am J Manag Care. 2012;18:S55-S61.
- Executive Summary: Standards of medical care in diabetes 2013. Diabetes Care. 2013 Jan;36 Suppl 1:S4-S10.
- Tuchman AC. History of diabetes. MDAdvisor. 2013;Winter:8-13.