Failing Our ABCs.
Evan David Rosen, M.D., Ph.D. Assistant Professor of Medicine, Harvard
Medical School
OK,
here’s the thing. I was about to write a terrific column
about some new advance in our understanding of type 2 diabetes and obesity,
but an article published in last week’s Journal of the American
Medical Association (JAMA) made me lose my train of thought. In fact,
if you or someone you love has diabetes, this article should make you
pause as well. Was it about an exciting new development in stem cell
technology? Perhaps a new anti-obesity pill hitting the market? Or maybe
a way to increase the number of successful islet cell transplants?
Uhhhh…no. This article isn’t going to push some lucky biotech
firm’s stock through the roof, and certainly won’t garner
any votes for “Medical Breakthrough of the Year”
.
This paper is about as much fun as a report card. In fact, it IS a report
card, and the course being graded is "Appropriate Diabetes Care
101". And guess what America?
We failed. Again.
The paper details information collected from the National Health and
Nutrition Examination Survey, known by its acronym NHANES. The NHANES
studies have been going on for a long time, and several different versions
have appeared over the years. The most recent one was performed between
1999-2000, so it was given the catchy name NHANES 1999-2000. It was
a follow-up study to the last NHANES study done between 1988-1994 (NHANES
III).
The way the NHANES data are collected is a little complicated, but
they are basically giant surveys taken of representative folks in the
U.S., people like you and me. Participants got a home visit from a study
nurse, answered some basic questions about health, diet, exercise, etc…,
and then underwent some simple tests like blood pressure readings, cholesterol
levels, and hemoglobin A1c. This was done on almost 19,000 people in
NHANES III, and a little less than 5,000 more in NHANES 1999-2000.
In both NHANES III and NHANES 1999-2000, about 5-6% of the total number
of people reported having diabetes, so that for the purposes of the
paper we’re discussing now, we’re talking about 1,265 diabetics
in NHANES III and 441 in NHANES 1999-2000.
The question this paper asks is quite simple: How many people with
diabetes are meeting recommended guidelines for hemoglobin A1c, Blood
pressure control, and Cholesterol (the so-called ABCs of diabetes care)?
The results were quite clear:
We recommend that hemoglobin A1c levels be kept at or below 7% to minimize
diabetic complications. In fact, only 37% of diabetics met this guideline,
no better than the number in NHANES III. An equal number of folks had
A1c levels greater than 8%, a level that is supposed to raise red flags
in the clinic for immediate action.
A similar number of people were in compliance with recommended blood
pressure levels; 36% had readings of 130/80 or lower. 40% were overtly
hypertensive, with a BP of greater than 140/90. These results were also
no better than those seen in NHANES III.
We did a little bit better with cholesterol, with a significant reduction
in the number of patients over target levels relative to NHANES III.
Lest you get too excited by this, over 50% of patients still had total
cholesterol of greater than the recommended level of 200 mg/dL.
If these numbers weren’t depressing enough, here’s one
more: only 7.3% of patients met all three recommended goals for A1c,
blood pressure and cholesterol. Let me state that one more time so it
sinks in. Only 7 out of every 100 Americans with diabetes has established
reasonable control of their glucose, blood pressure, and cholesterol
levels. This despite frequent papers reporting the results of large
trials demonstrating the benefits of these measures in the prevention
of nerve damage, blindness, dialysis, kidney transplant, amputation,
heart attack, stroke, and death. I mean, we’re not talking about
bunions here, people.
Furthermore, there are excellent therapeutic options for all of these
issues. The old standbys of diet and exercise combined with the appropriate
drugs can result in near normalization of glucose, cholesterol, and
blood pressure in virtually all people. The inability to significantly
improve our record in the time between NHANES III and NHANES 1999-2000
is nothing short of shameful, and reflects poorly on patients and physicians
alike.
I do not know what precise combination of factors will promote better
control of the ABCs, but it will surely involve some combination of
financial incentives and disincentives for physicians caring for diabetic
patients. Ultimately, however, the patient has to assume some control
over their own destiny, and accept responsibility for getting the care
they need.
If you have diabetes, you should not leave your doctor’s office
without getting an answer to the following three questions:
1. What is my most recent hemoglobin A1c?
2. What is my blood pressure?
3. What is my most recent cholesterol?
And then follow those up with the most important question of all:
What can we do to make this better?
Reference:
Sharon H. Saydah, Judith Fradkin, and Catherine C. Cowie. Poor Control
of Risk Factors for Vascular Disease Among Adults With Previously Diagnosed
Diabetes. Journal of the American Medical Association, Jan 2004; 291:
335 - 342.
