September 21, 2015

Why Are Doctors Waiting to Stop Diabetes

We have learned that preventing diabetes through lifestyle interventions is possible. This has been consistently reported in other clinical trials. While this is somewhat less effective in the real world, even translational studies of combined diet and physical activity programs have shown reduced diabetes risk. We are talking about people with pre-diabetes.

These programs are cost-effective and relatively inexpensive, especially when delivered in a group format, with a median cost per participant of less than $500. Unfortunately, no cost-benefit studies were identified, so we do not know how much of a long-term impact diabetes prevention may have on healthcare costs.

However, given that patients with diabetes incur medical expenditures that are more than twice as high as those of patients without diabetes, simple logic suggests that the impact could be substantial, even when considering that costs for people with pre-diabetes are already elevated. The biggest problem is we do not know the extent to which evidence-based diet-and-exercise diabetes prevention programs are being offered.

Although somewhat less effective than lifestyle, metformin has been shown to prevent diabetes in clinical trials. Metformin has been shown to be a cost-saving intervention and is clearly easier to deliver on a population-wide basis than diet and exercise programs. In patients with newly diagnosed diabetes, metformin is most effective when given at diagnosis and at lower A1c levels than if delayed, suggesting that beginning metformin before diabetes develops may further enhance its effectiveness.

Despite this evidence, and even though metformin is included in the American Diabetes Association guideline for diabetes prevention, only a small minority of patients at risk for diabetes are receiving metformin. If a relatively simple and inexpensive intervention is reaching less than 5% of its target population, we can imagine that a more complex and costly intervention will not fare any better. Of interest, the 5% treatment rate is actually an improvement over a previous study based on 2005-2006 National Health and Nutrition Examination Survey data, in which no patients with pre-diabetes were receiving metformin and only about one third had received advice about diet and exercise.

We know that type 2 diabetes is a major public health crisis and we know that it can be prevented. The Community Preventive Services Task Force has just issued a recommendation for promotion of combined diet and physical activity programs by healthcare systems, communities, and other implementers. For those unwilling or unable to participate, metformin offers a simple, low-cost, and effective alternative. What are doctors waiting for?

I am only guessing, but I feel that many doctors are not interested in treating pre-diabetes. I have heard doctors laugh about pre-diabetes and say they would not treat these people until they had something treatable. One doctor and I had a heated discussion about this in a hospital cafeteria until two other doctors ushered him away and one came back to ask me to leave and was none to polite about it. As I was leaving, I asked why it was that some doctors like to do harm to patients.

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