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Stanford University School of Medicine

Breaking down diabetes: Top priorities for patients and their doctors

This is the third in a series of blog posts by Randall Stafford, MD, PhD, discussing prediabetes and Type 2 diabetes.

Thirty million Americans have diabetes, a disease where the body loses its ability to remove enough sugar from the bloodstream, spurring harmful inflammation systemwide. While it’s better to prevent diabetes from developing, there are many strategies that patients and their doctors can take to avoid its deadly and devastating consequences: heart attacks, strokes, kidney failure, nerve damage, amputations, and blindness.

Yet many problems persist in how doctors, people with diabetes and the U.S. health care system overall manages this complex chronic illness, which costs $245 billion a year, according to the American Diabetes Association, equivalent to 10 percent of all health care expenses. The key issues are:

  • We don’t prepare patients well enough for the demanding work of managing diabetes.
  • Controlling blood sugar (glucose) shouldn't be the only focus of diabetes treatment.
  • Even for the limited goal of lowering blood sugar, we do poorly.
  • Medications are important, but physicians also need to emphasize health behaviors.

Let’s look at how to improve diabetes treatment, an effort that requires strong commitment from both patients and their doctors.

Provide patients with better training

Having diabetes means that a key part of how the body works is broken and cannot be repaired. As a result, managing diabetes involves finding workarounds for a very complicated set of internal functions. This means paying close attention to when medications are taken, following a strict diet, and being on the lookout for low blood sugar. Patients need to complete these tasks every single day. The training people with diabetes receive to do this 24/7 job just isn’t adequate. A good first step for most patients is to see themselves as their own diabetes health care manager.

Broaden focus beyond just lowering blood sugar 

The overwhelming emphasis of current diabetes treatment is bringing down blood sugar levels so that they are closer to normal. While lowering blood sugar is critical to avoiding kidney failure, blindness, and amputations, it does not address the two main killers of people with diabetes: heart attacks and strokes. Preventing these major catastrophes requires attention to blood pressure, cholesterol levels, smoking, physical activity, diet, and using aspirin to offset the greater chance of forming blood clots.

Improve blood sugar control

Many people with diabetes have blood sugars levels that are too high. Long-term blood sugar is measured using the hemoglobin A1c blood test, a test that indicates the average blood sugar over the past three months. While 5.5 percent or less is normal, most people with diabetes should be less than 7 percent. In the U.S., A1c levels above 7 percent occur in 50 percent of people with diabetes, according to the National Health and Nutrition Examination Survery. One hurdle is that many patients don't feel ready for insulin injections.

Stress importance of behaviors in addition to medications

Medications are vital for treating diabetes, but they simply aren't enough. Patients have better outcomes if heart healthy behaviors are part of diabetes treatment, especially physical activity, reduced intake of simple carbohydrates, a mostly plant-based diet, weight loss, adequate sleep and no exposure to cigarettes. These strategies both lower blood sugar and reduce the inflammatory process that is part of diabetes.

Patients and physicians need to do a much better job of treating diabetes to avoid its terrible complications. We need a broader approach to stroke and heart attack prevention and a greater focus on health behaviors with patients trained to take a larger role in self-management.

This is the third in a series of blog posts discussing prediabetes and Type 2 diabetes. The first installments examined what happens inside the body in pre-diabetes, and how to stop prediabetes from progressing. The next post will focus on a brief review of the complications of diabetes.

Randall Stafford, MD, PhD, a professor of medicine and director of the Program on Prevention Outcomes and Practices, practices primary care internal medicine at Stanford. He is developing practical strategies to improve how physicians and consumers approach chronic disease treatment and prevention.

Photo by Glenn Carstens-Peters

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