The Diabetes Epidemic: Can We Stop the Spread?
The Diabetes Epidemic: Can We Stop the Spread?
When I first became involved with diabetes education and management 10 years ago, I had no idea it would become a growth industry, both literally and figuratively (Figure 1). In 1993, when the results of the Diabetes Control and Complications Trial were published, approxi-mately 7.5 million people -- roughly 3% of the population -- were diagnosed with diabetes mellitus. Today more than 13 million people in the United States -- over 4% of the population -- are known to have diabetes and another 5 million are unaware that they have it. Throw in another 12-16 million Americans with impaired glucose tolerance or "prediabetes," and the grand total is over 30 million Americans -- nearly 1 in 10 -- who have a disorder of glucose metabolism. And things are not likely to get better anytime soon. An estimated 1 million new cases are diagnosed each year. By 2010, more than 17.5 million people are predicted to be diagnosed with diabetes and the prevalence will reach 5.2% of the population.
(Enlarge Image)
Increasing prevalence of diabetes (including gestational diabetes) by state from 1990-2001.[2]
The dramatic increase in the prevalence of diabetes is fueled by several factors. First, type 2 diabetes mellitus is a disorder of the elderly. Over 20% of individuals aged 65 or older have diabetes, and the oldest members of the baby boom generation are now "senior" citizens. Second, type 2 diabetes disproportionately affects the segments of the U.S. population that are increasing most rapidly. Hispanics, Asians, African-Americans, and Native Americans are twice as likely to develop diabetes compared with individuals of European ancestry. Third, type 2 diabetes is closely linked to obesity. Insulin resistance is induced by resistin and other hormones secreted by adipose tissue. Similar to diabetes, the prevalence of obesity has increased at a double-digit pace over the past decade, most likely the result of cheap, "supersized" meals and dwindling physical activity. As the rate of obesity has nearly tripled in children, type 2 diabetes, virtually unheard of in adolescents a decade ago, is commonplace in pediatric clinics today.
Other statistics are equally grim. Diabetes is the sixth most common cause of death in the United States, a primary contributor to heart disease and stroke, and the leading cause of blindness, end-stage kidney disease, and nontraumatic limb amputation. In 2002, the cost of diabetes to our society was a staggering $132 billion! That equates to nearly 1 of every 5 dollars spent on health care. People with diabetes spend $21.6 billion/year -- nearly 30% of the U.S. total -- on prescription drugs, insulin, and monitoring supplies. This is likely the largest and most important market for the goods and services delivered by pharmacists.
Unfortunately, the response by health care professionals to the diabetes epidemic has been anemic despite the publication of numerous studies over the past decade. The landmark Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Study demonstrated that achieving near-normal blood glucose control lowers the risk of developing retinopathy, nephropathy, and neuropathy in patients with types 1 and 2 diabetes. Additional studies, including the Hypertension Optimal Treatment (HOT) trial, the Heart Outcomes Prevention Evaluation (HOPE) study, the Cholesterol and Recurrent Events (CARE) trial, the Heart Protection Study, and the Steno-2 trials, provided strong evidence that aggressive management of blood pressure and lipid levels, as well as the routine use of angiotensin-converting enzyme inhibitors and antiplatelet drugs, cut the risk of cardiovascular disease by 50% in people with diabetes. Lifestyle changes directed at increasing physical activity, reducing caloric intake, limiting saturated fat, and consuming more complex carbohydrates substantially improve cardiovascular risk factors and, in individuals with prediabetes, reduce the progression to diabetes by nearly 70%.
In spite of a tremendous increase in our knowledge, the development of several new drugs, and advancements in technologies, the person with diabetes or prediabetes often is poorly served by our fractionated health care system. One approach that can improve diabetes management is implementation of a multidisciplinary diabetes care team. The team approach amplifies the system of care by integrating the skills of the patient and the patient's family members with the guidance of several health care professionals, coupled with community-based resources. At the center of the diabetes care team is the patient with diabetes (Figure 2). Ultimately, the patient is responsible for the day-to-day management of the disease. Team composition varies based on the patient's needs and the organizational structure, available resources, clinical setting, and professional skills of the team members.
(Enlarge Image)
The diabetes care team.
The benefits of a multidisciplinary team approach to diabetes management are well established. In the acute care setting, team management results in shorter lengths of hospital stay and lower readmission rates. In the outpatient setting, patients who receive coordinated care from an interdisciplinary team are less likely to develop the long-term complications associated with diabetes. With a team approach, patients are more likely to achieve recommended glycemic goals and have higher quality-of-life scores. Further, they are more likely to remain employed and less likely to be absent from work or school.
Given their accessibility to the public, particularly in underserved rural and inner-city areas, pharmacists are often a patient's first point of contact with the health care system and are well positioned to recognize people at risk for diabetes. Risk factors for type 2 diabetes are as follows:
Patients at risk should be strongly encouraged to lose weight and engage in regular physical activity. In addition, pharmacists should inform anyone with two or more risk factors to have fasting plasma glucose levels measured every 3 years and consider having an oral glucose tolerance test.
Pharmacists are serving in increasing numbers as integral members of the diabetes care team and becoming Certified Diabetes Educators (CDEs). Pharmacists can assist the diabetes team by taking comprehensive drug histories, screening for drug-drug and drug-disease interactions, providing drug therapy education, instructing patients regarding glucose self-monitoring and other self-care behaviors, and managing drug therapy. Most patients with diabetes take complex drug regimens that must be timed carefully with food intake. The pharmacist can help devise an individualized drug regimen that fits the patient's lifestyle. Since many patients with diabetes do not have insurance coverage for prescription drugs, the pharmacist can play a vital role by enrolling the patient in state-based or pharmaceutical manufacturer-sponsored patient assistance programs. By working collaboratively with physicians and other health care practitioners, pharmacists can help patients meet their goals for glycemic control, cholesterol, and blood pressure. The recently published Asheville project confirms that diabetes management programs based in community pharmacies can reduce health care costs, decrease absenteeism from work, and improve patient satisfaction. The evidence is clear: well-trained and motivated pharmacists can have a tremendous impact on diabetes and its complications.
Unfortunately, numerous barriers prevent health care providers, particularly pharmacists, from delivering optimal care to patients with diabetes and prediabetes. Effective communication is frequently lacking between team members. Health information systems often fail to deliver information in a useful and timely manner. The lack of prescription drug coverage for millions of Americans, including the elderly and other high-risk populations, limits our ability to provide patients with the tools necessary to control diabetes. Many patients lack the skills necessary to engage in diabetes self-management and only a limited number of community-based diabetes education programs exist. Whereas the majority of state pharmacy practice acts permit collaborative drug therapy management between pharmacists and physicians, payment for clinical pharmacy services is limited or nonexistent. Indeed, pharmacists are the only members of the diabetes care team who do not have provider status under Medicare, and no system for processing claims for patient care services provided by pharmacists exists.
To address these barriers, the American College of Clinical Pharmacy has an aggressive plan of action. Payment for clinical pharmacy services remains a priority under the College's advocacy agenda. Further, the association supports prescription drug coverage under Medicare provided it includes payment for drug therapy management services. [At the time of this writing, a Medicare Reform Act was being debated by Congress. Whether the prescription drug and drug therapy management provisions under the new legislation will be adequate to address the needs of the elderly remains to be seen.] But rational health care policies that align incentives for patients, providers, and payers will never come to fruition unless individual pharmacists are actively engaged in the political process and continually advocate for them.
The National Diabetes Education Program (NDEP) is an initiative sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention in partnership with professional associations, civic organizations, and patient advocacy groups. The goal of the NDEP is to reduce the morbidity and mortality associated with diabetes by:
The NDEP provides a variety of resources for patients and health care providers ( Table 1 ). Most of the patient education materials are available in Spanish, and some are available in Asian languages. The NDEP also produces media kits to assist local groups disseminate information about prediabetes and diabetes through newspapers, radio, and television. Materials have been developed to inform employers, insurers, school administrators, and policy makers about the diabetes epidemic and ways to address it. The Better Diabetes Care E-guide ( Table 1 ) provides a road map for health care institutions to make system changes to improve diabetes care. These materials are unbiased sources of information and are not copyright protected. Health care practitioners and civic organizations are encouraged to reproduce and disseminate them.
Regardless of your practice setting or area of expertise, the diabetes epidemic will have a tremendous impact, complicating the management of patients in every specialty service and draining away our already limited resources. Can we stop the spread? Perhaps, but this epidemic is far too big for any single group to tackle alone. Nor can we expect a handful of endocrinologists, CDEs, dieticians, and clinical pharmacists on diabetes care teams to meet the challenge. It will require a concerted effort by patients, all health care practitioners, employers, communities, and the government. Pharmacists can and should play an important role. Through our direct patient care activities, pharmacists can identify those at risk for diabetes and make significant contributions to the management of those patients who are diagnosed with a disorder of glucose metabolism. Given that drug therapy is an essential ingredient in the management of diabetes and has become increasingly complex, at least one pharmacist should be a member of every diabetes care team. Pharmacists in partnership with other health care professionals, employers, and members of the community (e.g., churches, civic organizations, and neighborhood associations) should be at the forefront of designing, implementing, and evaluating new models of care. Waiting for patients to come to us has not worked. In addition, pharmacists must be actively engaged in the political process by advocating for rational health care policies. Develop a relationship with your representatives by writing to them on important issues, calling and visiting them, and inviting them to visit you in your practice.
Although our knowledge and skills regarding drug therapy can help millions of individuals, it is only by constantly challenging the status quo and through leadership that we will have a meaningful and sustained impact on the diabetes epidemic.
When I first became involved with diabetes education and management 10 years ago, I had no idea it would become a growth industry, both literally and figuratively (Figure 1). In 1993, when the results of the Diabetes Control and Complications Trial were published, approxi-mately 7.5 million people -- roughly 3% of the population -- were diagnosed with diabetes mellitus. Today more than 13 million people in the United States -- over 4% of the population -- are known to have diabetes and another 5 million are unaware that they have it. Throw in another 12-16 million Americans with impaired glucose tolerance or "prediabetes," and the grand total is over 30 million Americans -- nearly 1 in 10 -- who have a disorder of glucose metabolism. And things are not likely to get better anytime soon. An estimated 1 million new cases are diagnosed each year. By 2010, more than 17.5 million people are predicted to be diagnosed with diabetes and the prevalence will reach 5.2% of the population.
(Enlarge Image)
Increasing prevalence of diabetes (including gestational diabetes) by state from 1990-2001.[2]
The dramatic increase in the prevalence of diabetes is fueled by several factors. First, type 2 diabetes mellitus is a disorder of the elderly. Over 20% of individuals aged 65 or older have diabetes, and the oldest members of the baby boom generation are now "senior" citizens. Second, type 2 diabetes disproportionately affects the segments of the U.S. population that are increasing most rapidly. Hispanics, Asians, African-Americans, and Native Americans are twice as likely to develop diabetes compared with individuals of European ancestry. Third, type 2 diabetes is closely linked to obesity. Insulin resistance is induced by resistin and other hormones secreted by adipose tissue. Similar to diabetes, the prevalence of obesity has increased at a double-digit pace over the past decade, most likely the result of cheap, "supersized" meals and dwindling physical activity. As the rate of obesity has nearly tripled in children, type 2 diabetes, virtually unheard of in adolescents a decade ago, is commonplace in pediatric clinics today.
Other statistics are equally grim. Diabetes is the sixth most common cause of death in the United States, a primary contributor to heart disease and stroke, and the leading cause of blindness, end-stage kidney disease, and nontraumatic limb amputation. In 2002, the cost of diabetes to our society was a staggering $132 billion! That equates to nearly 1 of every 5 dollars spent on health care. People with diabetes spend $21.6 billion/year -- nearly 30% of the U.S. total -- on prescription drugs, insulin, and monitoring supplies. This is likely the largest and most important market for the goods and services delivered by pharmacists.
Unfortunately, the response by health care professionals to the diabetes epidemic has been anemic despite the publication of numerous studies over the past decade. The landmark Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Study demonstrated that achieving near-normal blood glucose control lowers the risk of developing retinopathy, nephropathy, and neuropathy in patients with types 1 and 2 diabetes. Additional studies, including the Hypertension Optimal Treatment (HOT) trial, the Heart Outcomes Prevention Evaluation (HOPE) study, the Cholesterol and Recurrent Events (CARE) trial, the Heart Protection Study, and the Steno-2 trials, provided strong evidence that aggressive management of blood pressure and lipid levels, as well as the routine use of angiotensin-converting enzyme inhibitors and antiplatelet drugs, cut the risk of cardiovascular disease by 50% in people with diabetes. Lifestyle changes directed at increasing physical activity, reducing caloric intake, limiting saturated fat, and consuming more complex carbohydrates substantially improve cardiovascular risk factors and, in individuals with prediabetes, reduce the progression to diabetes by nearly 70%.
In spite of a tremendous increase in our knowledge, the development of several new drugs, and advancements in technologies, the person with diabetes or prediabetes often is poorly served by our fractionated health care system. One approach that can improve diabetes management is implementation of a multidisciplinary diabetes care team. The team approach amplifies the system of care by integrating the skills of the patient and the patient's family members with the guidance of several health care professionals, coupled with community-based resources. At the center of the diabetes care team is the patient with diabetes (Figure 2). Ultimately, the patient is responsible for the day-to-day management of the disease. Team composition varies based on the patient's needs and the organizational structure, available resources, clinical setting, and professional skills of the team members.
(Enlarge Image)
The diabetes care team.
The benefits of a multidisciplinary team approach to diabetes management are well established. In the acute care setting, team management results in shorter lengths of hospital stay and lower readmission rates. In the outpatient setting, patients who receive coordinated care from an interdisciplinary team are less likely to develop the long-term complications associated with diabetes. With a team approach, patients are more likely to achieve recommended glycemic goals and have higher quality-of-life scores. Further, they are more likely to remain employed and less likely to be absent from work or school.
Given their accessibility to the public, particularly in underserved rural and inner-city areas, pharmacists are often a patient's first point of contact with the health care system and are well positioned to recognize people at risk for diabetes. Risk factors for type 2 diabetes are as follows:
|
Patients at risk should be strongly encouraged to lose weight and engage in regular physical activity. In addition, pharmacists should inform anyone with two or more risk factors to have fasting plasma glucose levels measured every 3 years and consider having an oral glucose tolerance test.
Pharmacists are serving in increasing numbers as integral members of the diabetes care team and becoming Certified Diabetes Educators (CDEs). Pharmacists can assist the diabetes team by taking comprehensive drug histories, screening for drug-drug and drug-disease interactions, providing drug therapy education, instructing patients regarding glucose self-monitoring and other self-care behaviors, and managing drug therapy. Most patients with diabetes take complex drug regimens that must be timed carefully with food intake. The pharmacist can help devise an individualized drug regimen that fits the patient's lifestyle. Since many patients with diabetes do not have insurance coverage for prescription drugs, the pharmacist can play a vital role by enrolling the patient in state-based or pharmaceutical manufacturer-sponsored patient assistance programs. By working collaboratively with physicians and other health care practitioners, pharmacists can help patients meet their goals for glycemic control, cholesterol, and blood pressure. The recently published Asheville project confirms that diabetes management programs based in community pharmacies can reduce health care costs, decrease absenteeism from work, and improve patient satisfaction. The evidence is clear: well-trained and motivated pharmacists can have a tremendous impact on diabetes and its complications.
Unfortunately, numerous barriers prevent health care providers, particularly pharmacists, from delivering optimal care to patients with diabetes and prediabetes. Effective communication is frequently lacking between team members. Health information systems often fail to deliver information in a useful and timely manner. The lack of prescription drug coverage for millions of Americans, including the elderly and other high-risk populations, limits our ability to provide patients with the tools necessary to control diabetes. Many patients lack the skills necessary to engage in diabetes self-management and only a limited number of community-based diabetes education programs exist. Whereas the majority of state pharmacy practice acts permit collaborative drug therapy management between pharmacists and physicians, payment for clinical pharmacy services is limited or nonexistent. Indeed, pharmacists are the only members of the diabetes care team who do not have provider status under Medicare, and no system for processing claims for patient care services provided by pharmacists exists.
To address these barriers, the American College of Clinical Pharmacy has an aggressive plan of action. Payment for clinical pharmacy services remains a priority under the College's advocacy agenda. Further, the association supports prescription drug coverage under Medicare provided it includes payment for drug therapy management services. [At the time of this writing, a Medicare Reform Act was being debated by Congress. Whether the prescription drug and drug therapy management provisions under the new legislation will be adequate to address the needs of the elderly remains to be seen.] But rational health care policies that align incentives for patients, providers, and payers will never come to fruition unless individual pharmacists are actively engaged in the political process and continually advocate for them.
The National Diabetes Education Program (NDEP) is an initiative sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention in partnership with professional associations, civic organizations, and patient advocacy groups. The goal of the NDEP is to reduce the morbidity and mortality associated with diabetes by:
|
The NDEP provides a variety of resources for patients and health care providers ( Table 1 ). Most of the patient education materials are available in Spanish, and some are available in Asian languages. The NDEP also produces media kits to assist local groups disseminate information about prediabetes and diabetes through newspapers, radio, and television. Materials have been developed to inform employers, insurers, school administrators, and policy makers about the diabetes epidemic and ways to address it. The Better Diabetes Care E-guide ( Table 1 ) provides a road map for health care institutions to make system changes to improve diabetes care. These materials are unbiased sources of information and are not copyright protected. Health care practitioners and civic organizations are encouraged to reproduce and disseminate them.
Regardless of your practice setting or area of expertise, the diabetes epidemic will have a tremendous impact, complicating the management of patients in every specialty service and draining away our already limited resources. Can we stop the spread? Perhaps, but this epidemic is far too big for any single group to tackle alone. Nor can we expect a handful of endocrinologists, CDEs, dieticians, and clinical pharmacists on diabetes care teams to meet the challenge. It will require a concerted effort by patients, all health care practitioners, employers, communities, and the government. Pharmacists can and should play an important role. Through our direct patient care activities, pharmacists can identify those at risk for diabetes and make significant contributions to the management of those patients who are diagnosed with a disorder of glucose metabolism. Given that drug therapy is an essential ingredient in the management of diabetes and has become increasingly complex, at least one pharmacist should be a member of every diabetes care team. Pharmacists in partnership with other health care professionals, employers, and members of the community (e.g., churches, civic organizations, and neighborhood associations) should be at the forefront of designing, implementing, and evaluating new models of care. Waiting for patients to come to us has not worked. In addition, pharmacists must be actively engaged in the political process by advocating for rational health care policies. Develop a relationship with your representatives by writing to them on important issues, calling and visiting them, and inviting them to visit you in your practice.
Although our knowledge and skills regarding drug therapy can help millions of individuals, it is only by constantly challenging the status quo and through leadership that we will have a meaningful and sustained impact on the diabetes epidemic.
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