For clinicians working in primary care, the very thought of seeing a patient with newly-diagnosed type 2 diabetes (T2DM) can be cause for consternation. Ever-shorter appointment times, ever-longer lists of medications that require prior-approval, and the demands of electronic medical records add to the challenge of managing the complexities of the disease and the complications that are often present at the time of diagnosis.
For those of you who have been in practice for a while and find that increasing numbers of your patients have diabetes, you are not imagining it. In their most recent Diabetse Report Card published in 2014, the CDC reported that over the past 32 years the number of adults with diabetes has nearly quadrupled to 21.3 million.1 The report further states that there are 1.7 million new cases diagnosed annually with a predicted prevalence of one in every three adults by 2050.1 The estimated healthcare costs are just as staggering with a projected $176 billion in direct medical costs and $69 billion in indirect costs due to lost productivity, disability, and premature death.1 As “front line” physicians it is nothing short of imperative that we initiate preventive measures, make timely diagnoses, and employ optimal medical management for each of our patients with T2DM.
The prequel to the diagnosis of T2DM can span years to decades and begins with insulin resistance. As insulin resistance worsens, pancreatic beta cells are initially able to compensate by increasing insulin levels, resulting in hyperinsulinemia.2 This compensatory mechanism can maintain blood glucose levels within the normal range for up to several years but the consequence impaired glucose tolerance, most notably manifested as mild postprandial hyperglycemia.2 By the time diabetes is diagnosed, it is estimated the approximately 50% of beta cell function has been lost.3 It should come as no surprise then that at the time of diagnosis more than 20% of patients will have chronic macro- and/or microvascular complications.
Without a doubt, this is a challenging patient population to effectively treat. Conceptually, we know that if our obese patients could lose weight, their diabetes could often be managed by nutrition and lifestyle alone; and yet what we are asking patients to do in order to control their disease is not simply to “lose weight;” we are asking them to essentially change everything from their food preferences to their day-to-day lifestyle habits. And this is often how we as clinicians, most often unknowingly, start with the very best of intentions yet slump into that state of medical limbo called clinical inertia.
(Image: beta cells on surfact of pancreas)
- Centers for Disease Control and Prevention. Diabetes Report Card 2014. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2015. www.cdc.gov/diabetes/library/reports/congress.html
- Ramlo-Halsted BA, Edelman SV. The natural history of type 2 diabetes: practical points to consider in developing preventing and treatment strategies. Clinical Diabetes 2000; 18(2). http://journal.diabetes.org/clinicaldiabetes/v18n22000/pg80.htm
- Gallwitz B. The fate of beta cells in type 2 diabets and the possible role of pharmacological interventions. Rev Diabet Stud. 2006;3:208–216.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1828283/