Today there were several articles in the New York Times (Monday, August 20, 2007) that had to do with treatment of diabetes in the U.S. Gina Kolata authored 3 of the articles, including one on the front page of the newspaper entitled “Looking Past Blood Sugar To Survive With Diabetes.” The gist of the articles was to emphasize in fairly dramatic fashion that patients with diabetes need to be concerned about complication risk factors beyond blood sugar levels. Ms. Kolata profiled Dave Smith, a 43-year-old pastor from Minnesota who was diagnosed with type 2 diabetes about 9 years ago. Apparently, Pastor Smith had a heart attack last October and was surprised to learn that diabetes is a well-known risk factor for heart disease. The article went on to document how poorly people, and presumably their health-care providers, understand diabetes complications risk factors.
What’s my gripe?
Ms. Kolata did interview a number of very smart diabetes specialists all of whom addressed the issue of diabetes complications risk factors beyond blood sugar levels (mostly blood lipid levels and blood pressure levels). So what’s my problem? Answer: scientists have known about these risk factors for quite some time and the fact that so many peopleÂ apparently are clueless about them is disturbing. Is it patients with diabetes who have been taught about these risks but have ignored or forgotten them? Is it physicians who have never been taught about these risks or who have ignored or forgotten them? Is it a health-care system that creates barriers to optimal diabetes care?
What can we learn from Kaiser-Permanente?
Kaiser-Permanente is a large HMO which years ago learned that comprehensive care of people with chronic diseases was good for business and good for patients. They have devoted considerable resources to managing certain chronic diseases including cancer, heart disease, and diabetes. I do not know all the details but their outcomes data for diabetes are dramatically better than the national average. I can assure you that the Kaiser care-givers are well-aware that diabetes complications are strongly related to blood sugars, lipids (e.g., cholesterol levels), and blood pressure and do their best to decrease risks. So what’s wrong with the rest of us? Is it our lousy health-care delivery system? I don’t know the answer but I would have liked Ms. Kolata to have focused on the failures of our health-care delivery system. We do how to prevent diabetes complications, including heart disease. There is no new medical news here. Clearly, we need to do better. I am skeptical that we can achieve meaningful gains unless we invest in major changes to our health-care delivery system. Certainly the people at Kaiser have taught us that.
Last but not least
In ending this little critique I want to be certain that readers of the New York Times pieces today are not misled in thinking that blood sugar levels are not all that important risk predictors for diabetes complications. Nothing is further from the truth. It is true that the Diabetes Control and Complications Trial (DCCT) follow-up data did not show for many years (2006) that blood sugar levels were important risk factors for cardiovascular disease; links between blood sugar levels and eye, kidney, and nerve disease were shown in 1993. The fact that it took a long time for the data to achieve statistical significance was to a great extent related to the fact that patients at onset of the study in 1983 were relatively young (13-39 years of age), had diabetes of short duration, and were free from heart disease and hypertension. As noted in one of Ms. Kolata’s articles, the links between hypertension and lipid abnormalities and heart disease in patients with type 2 diabetes were established in 1998 with publication of the United Kingdom Prospective Diabetes Study (UKPDS).
So, it is now well-established that blood sugar control, lipids, and blood pressure are the key risk factors for complications in patients with either type 1 or type 2 diabetes. The good news is that these risk factors can all be treated, thereby greatly diminishing risks for development of these serious complications. As I recall it is 2007, and in my opinion, any physician who does not know this information should not be caring for people with diabetes.
I’m feeling a little guilty.Â Maybe I should not have been so critical of Ms. Kolata’s articles.Â After all she did document nicely our rather astonishingly poor approach to managing diabetes in the U.S.Â I only wish she would have put much more emphasis on what we already know about managing diabetes and raising questions about why we are doing such a poor job in caring for people with diabetes.l
- Type 1 Diabetes Mellitus and Intensive Exercise
- What Should People With Diabetes Know?