Sometimes, inside the health-care professions and health-care regulatory agencies, we hear the opinion that type 2 diabetes isn't that big a deal. It isn't cancer and it isn't AIDS. It's just a lifestyle disease. People shouldn't have let themselves get overweight. There are lots of pills available, and then there's always insulin. It is amazing how often physicians don't even bother to tell people that they have diabetes; they soften the message with euphemisms like, "We'll have to watch your sugar," or the oldest of all, "You only have a touch of diabetes."
Statistics do not support this casual attitude. Available through the American Diabetes Association's Web site, www.diabetes.org, the numbers are sobering: 15.7 million people have diabetes in the United States, and about 5.4 million don't even know it. Over 200,000 people will die of diabetes this year. About 15 percent of diagnosed people already have long-term complications when they are first told they have diabetes, and the mean time between onset and diagnosis is estimated to be seven years. Type 2 diabetes is the leading cause of end-stage renal disease, preventable amputations, working-age blindness, and a major cause of heart disease and stroke. It cost over $98 billion in the United States in 1997. The stats go on, and paint an ugly picture of inadequate treatment with devastating results.
But isn't diabetes easily treated? Isn't it a disease people can easily take care of, if they would only pay attention? "Easily" is a huge misconception. It may be easy to say, "Diet and exercise, give up on the sweets, check your numbers, know your blood pressure and cholesterol and stop smoking, have your eyes checked, your feet, your lipids and your A1c. Oh yes, and keep losing the weight." But have you, the reader, ever tried to take such good care of your health? Probably only if you have diabetes.
Adding things up, people with diabetes are expected to think about their disease perhaps 20 to 30 times a day, between worrying every time they eat, exercise, check their blood sugar or take a medication.
As new medications and new technologies are developed, it is worth thinking about what they mean for the person with diabetes. The new is too often dismissed by a summary comment: "Too expensive;" "a convenience item;" "too complicated for the average patient;" "not proven to be better." These put-downs were probably used when disposable syringes replaced boiling glass syringes, when ultrafine needles replaced thick needles. (I talked with a person the other day who had found the pan her deceased mother used to boil her glass syringe). Better drugs, better meters, insulin pens and pumps translate into better self-care and fewer complications. And "too complicated" almost never applies: very little is too complicated for the average patient, and they need all the help they can get.
What about too complicated for the health-care professional? Those of us specializing in diabetes may be able to keep the medication options and the monitoring guidelines reasonably straight in our minds. But when diabetes is only a small part of a person's professional practice, it does present a huge challenge. In my opinion, the best thing to come along in the treatment of diabetes is the Certified Diabetes Educator, or CDE. It is a whole profession of people trained and certified in helping people with diabetes take care of themselves. People with diabetes and physicians who care for them should take advantage of the CDE.
So if diabetes is so complicated, so difficult to manage for the patient and health-care professional alike, is there any point trying? The evidence all points to a resounding "Yes." Large, definitive clinical trials such as the Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Study have proven conclusively that not only do blood glucose control and control of other risk factors matter, but they are achievable.
I believe, therefore, that it is up to us in the health-care professions and the health segment of the government to keep pushing the medications and the technologies forward. A safe, reliable pill to help people lose weight, regardless of whether it independently affects blood glucose, would have an enormous effect in controlling diabetes, since obesity-related insulin resistance is the major underlying cause of type 2 diabetes. Thousands of people with diabetes will benefit from any new medication that some people will respond well to, that has fewer side effects, or that will keep some people off insulin for a while longer. Dramatic advances like continuous or non-invasive blood glucose monitoring will come gradually and incrementally.
It must always be remembered that the cost of diabetes is in the complications and in the personal toll it takes. The incremental expense of new drugs and new technologies makes up a relatively small part of the total cost of diabetes. We therefore have to continue the progress in making safe, effective drugs and devices available until treatment is as easy as taking an aspirin a day.
Christopher D. Saudek, M.D., is president of the American Diabetes Association and director of the diabetes center at the Johns Hopkins School of Medicine in Baltimore.
FDA Consumer, 2002
