“We are aware of the American tendency to snack on carbohydrate-rich food throughout the day. So why is it we stubbornly obtain fasting glucose levels in our patients at risk?” asked R. Paul Robertson, MD Editor-in-Chief, the Journal of Clinical Endocrinology & Metabolism, in an Endocrine News commentary, Prevention of Type 2 Diabetes: Impossible Dream or a Matter of Implementation.1
Dr. Robertson added that research has “conclusively shown that lifestyle modification and metformin treatment are successful in the prevention or delay of the onset of type 2 diabetes for at least 10 years.” Despite the unequivocal facts, endocrinologists are not getting it done.
To explore the disconnect between evidenced base knowledge and the delivery of optimal clinical care members of the EndocrineWeb editorial board were asked to share their thoughts on the way forward in managing diabetes in 2017.
"Dr. Paul Robertson’s editorial is very welcome, timely, and reissues the concerns voiced by many of us over the past few years," said J. Michael Gonzalez-Campoy, MD, PhD, FACE, medical director of the Minnesota Center for Obesity, Metabolism, and Endocrinology in Eagan. MN.
"The knowledge that the adipocyte is an endocrine cell, and that adipose tissue is an endocrine organ required a new approach to the management of overweight and obesity," said Dr. Gonzalez-Campoy. "Adipose tissue may become diseased, contributing to the development of hyperglycemia, dyslipidemia, hypertension, male hypogonadism and cardiovascular disease (adiposopathy). Therefore, the goals of treatment for people [who are] overweight or obese are to decrease the burden of fat mass (adiposity), and to return adipose tissue function to normal," he continued.
“The opinions expressed by Dr. Robertson make great sense to me,” said Joshua D. Safer, MD, associate professor of medicine at Boston University School of Medicine, Boston, MA. “If the agenda is to get people to consume fewer calories and to exercise more, strategies to those ends are required, not simply berating people”
We may, for example, get some people to consume fewer calories if confronted with the numbers reliably, said Dr. Safer. But more effective solutions are needed to both reduce the incidence and forestall the complications that are inevitable in most people who develop diabetes.
“Despite all the scientific advances of the last 100 years in our understanding of diabetes and its management, we remain fundamentally human in our abilities to implement these advances,” said Elena A. Christofides, MD, is chair of the Department of Internal Medicine in the Division of Endocrinology at Mount Carmel Health Systems in Columbus, OH.
“I agree…that some of the barriers originate within medicine itself,” Dr. Safer added. It makes no sense to declare people fine during the period when they have not yet developed our strict definition of the disease (e.g. when fasting blood glucose is above 100 mg/dL, which is clearly abnormal but not yet at our diagnostic cut-off of 126 mg/dL), rather than alerting them to their situation and aggressively working with them to avoid progression.
While patient-centered care is heralded as the most model to be embraced if we are to overcome many of the barriers to diabetes care and obesity management, target-driven systems may make this model difficult to deliver.2
A good place to start might be in appreciating some of the changes reflected in the recently updated recommendations issued by the American Diabetes Association,3 such as recognizing that patients are much more than the disease that brings them to the clinician’s office, stating that “diabetes does not define people, the word ‘diabetic’ will no longer be used when referring to individuals with diabetes in the Standards of Medical Care in Diabetes.”
Similarly, Amy Hess-Fischl, MS, RD, CDE, found the questions posed by Dr. Richardson “a loud cry for action -- we know diabetes can be prevented, yet we, as a society, are not fully embracing the concept or, the possible ramifications,” said Ms. Hess-Fischel.
“For many people, access is a major hurdle,” said Dr. Christofides. “Access to expertise, resources, and the tools needed to affect change remain elusive for many here in the US and globally.”
Dr. Gonzalez-Campoy concurred, "the single biggest obstacle for this to happen is the lack of coverage for medical services for these patients. Moving forward we must overcome the social, political and economic obstacles that prevent patients with overweight or obesity from gaining access to needed medical care."
"Asking the questions during a consultation has been found more time efficient and patient-focused. The current reimbursement model that focuses on patient volume—seeing more patients in 7-minute (or so) time increments--may actually result in less effective care overall; whereas, a holist approach may afford the health care team to work with a variety of personal issues, such as literacy; limitations in language, time, transportation, child care needs; affordability of care; and mental health challenges,3 as spotlighted in the updated ADA medical standards.
Now that Medicare is proposing that the National Diabetes Prevention Program be opened to all participants by 2018, this may encourage people at risk of diabetes, and the healthcare professionals who treat them, to take a more proactive role in facing the barriers and addressing patients needs, suggested Ms. Hess-Fischl.
“With an epidemic disease like diabetes, it makes no sense to hide early disease by screening with fasting blood sugars, rather than more sensitive post-prandial sugars,” said Dr. Safer. This may be a good example of the need to the time to know your patient, and your patient’s needs, and to adjust your practice to reflect the last evidence-based care.3,4
Given the prevalence of children and adults who have and will develop diabetes in the United States, a shortage of endocrinologists, recognized in 2003,5 will pose a substantial barrier to addressing diabetes management thoroughly and effectively. Just knowing that there are too few physicians will mean less time for patients to be seen once they arrive at the office, longer waiting time for patients to get appointments and too little time for the patient to receive a comprehensive understanding to the responsibilities required to properly self-manage their care between appointments.6,7
Really, the recognized need to reign in health care costs across the spectrum of care5 must be extended to the barriers prohibiting adequate care for people who have or will develop diabetes, said these experts. The obvious solution is to realign the pay model to support prevention and education, rather than incentivizing late-term complications, and the complexities of managing common comorbidities.
Community-based support systems have also been recommended to improve care and reduce the healthcare burden.2,6
Another recent theme points to the need for health care teams to embrace the role of obesity as a critical part of diabetes management in order to provide the care needed to improve health outcomes and reduce costs.3,7
Ms. Hess-Fischl suggests that the guidelines in the Joint Position Paper for Diabetes Self-Management Education and Support8 should be extended to the management of prediabetes care, as well.
While we know that the number of people who receive diabetes self-management education with newly diagnosed diabetes is insufficient, it is essential that this change if we are ever to reverse the rising prevalence of diabetes, said Ms. Hess-Fischl. It is our moral and professional obligation to shout it from the rooftops that diabetes education is valuable and improves outcomes. And, it is the best means possible to prevent diabetes from developing.
Clinicians will be faced with an unprecedented number of new patients in the coming year, applying a patient-centered practice model that employs the recommendation of the latest professional guidelines.
"For many of our colleagues, obesity medicine is their calling," said Dr. Gonzalez-Campoy. "The American Board of Obesity Medicine recognizes this focus of practice by certifying [clinicians] as diplomates in this medical specialty. For clinical endocrinologists, obesity is now an endocrine disease. We have the knowledge and the tools. Now we need broader implementation."
1. Robertson RP. Prevention of Type 2 Diabetes: Impossible Dream or a Matter of Implementation. Endocrine News. Available at: http://endocrinenews.endocrine.org/prevention-type-2-diabetes-impossible-dream-matter-implementation. Accessed on November 16, 2016.
2. Harwood E, Bunn C, Caton S, Simmons D. Addressing barriers to diabetes care and self-care in general practice: A new framework for practice nurses. J Diabetes Nursing. 2013;17(5):186–91.
3. American Diabetes Association 2017 Standards of Care Diabetes Care. 2017; 40(Supplement 1): S4-S5. https://doi.org/10.2337/dc17-S003
4. Young-Hyman D; de Groot M, Hill-Briggs F, Gonzalez JS, Hood K, Peyrot M. Psychosocial Care for People With Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care. 2016;39:2126–2140
6. Stewart AF. The United States endocrinology workforce: a supply-demand mismatch. J Clin Endocrinol Metab. 2008;93(4):1164-1166.
7. A Report by the State Healthcare Cost Containment Commission. Cracking the code on healthcare costs. 2014. University of Virginia: Charlottesville, VA. Miller Center Available at: http://web1.millercenter.org/commissions/healthcare/HealthcareCommission-Report.pdf. Accessed December 27, 2016.
8. Powers MA, Bardsley J, Cypress M. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. J Acad Nutri Diet. 12015;155(8):1323-1334.