Team effort best way to control diabetes

Washington -- As rates of type 2 diabetes reach epidemic proportions, health care professionals are confronting an uncomfortable reality: The management of this condition is leaving a lot to be desired. Now, a group of physicians, educators and behavioral scientists say a team approach is essential if there is to be any hope of stemming an expected onslaught of disease as a result of the growing incidence of poorly controlled blood glucose levels.

Meeting as the Diabetes Roundtable, these experts concluded that it's unrealistic to expect a single physician, under the constraints of a 5- to 10-minute office visit, to successfully manage this complex disease.

Convened by the American Assn. of Clinical Endocrinologists and the American Assn. of Diabetes Educators, with funding from Merck & Co., roundtable members called on the medical community to take a more collaborative approach to caring for people with type 2 diabetes. A briefing was held May 31 to provide specific suggestions.

"There's a tidal wave headed our way, and we're ignoring it," said S. Sethu K. Reddy, MD, chair and program director for Cleveland Clinic's Dept. of Endocrinology, Diabetes and Metabolism. Dr. Reddy, a roundtable member, spoke at the briefing.

Nearly 21 million people in the United States, or 7% of the population, have diabetes, and many of them don't even know it, according to a new data analysis by the Centers for Disease Control and Prevention. Often patients and their physicians fall short in controlling blood glucose levels despite everyone's understanding that diabetes is the most common cause of blindness, kidney failure and amputations in adults and a major cause of heart disease and stroke.

Although there is no single correct way to provide team care for a patient, panelists suggested involving the patient, primary care physician, endocrinologist and diabetes educator -- often a nurse, dietician or pharmacist -- as well as other specialists such as podiatrists, ophthalmologists and behavioral scientists.

Patients should be in the driver's seat. Diabetes is a self-managed disease, the panelists noted. "To be successful, patients must take responsibility for their care and remain at the center. ... Their physician and other team members must, in turn, continue to teach, nurture and guide the patient toward self-management," according to roundtable findings.

"For the last 50 or 60 years, there has been a top-down approach to care, with doctors at the top," and that should change, Dr. Reddy said.

Start with small steps to avoid overwhelming a patient, the group suggested. Identify and focus on one or two behaviors that the patient is willing to attempt to change. For example, a physician might say, "Tell me how the monitoring is going," rather than ask "Are you monitoring three to four times a day?"

Ask patients to describe their goals, which might differ from those of the physician, the group suggested. Patients who are allowed to participate in goal-setting are more likely to adhere to a plan to achieve them, the panel said.

Adopting the necessary changes will mean making major modifications and maintaining them for life, the group said. To this end, patients should be encouraged to enlist a diabetes educator, dietician or behavioral scientist to help. Medicare and many other health insurers often will cover the charges, Dr. Reddy said.

"Although we know what we need to do to stay healthy, it's hard to do it," said Edwin Fisher, PhD, chair of Health Behavior and Health Education at the University of North Carolina-Chapel Hill. There is a need for ongoing support and follow-up to keep patients motivated, he said.

Survey results

For the education effort to go forward, some information gaps should be filled, panelists said. A survey commissioned by the diabetes educators and analyzed by the roundtable group revealed a disconnect between what patients with type 2 diabetes and primary care physicians believe is the state of diabetes management.

Although two-thirds of the patients surveyed said they felt knowledgeable about managing their condition, 81% of physicians said they are frustrated with patients and didn't think they closely followed treatment regimens.

The survey also uncovered gaps in understanding by both the patient and physician on how the disease progresses. Half of the patients surveyed said they had little or no understanding of their A1C levels and that they didn't believe their levels had been checked in the past six months.

For patients to self-manage their condition, it is important for them to understand the basics and the progression of their disease, including the role of declining pancreatic beta cell function, Dr. Reddy said.

The online survey, which was carried out in April by Harris Interactive, also found that the majority of the primary care physicians surveyed, or 78%, said insulin resistance is the most important contributor to, and is primarily responsible for, the progression of type 2 diabetes in the majority of their patients. Only 20% said it was beta cell dysfunction.

"This suggests that primary care physicians do not consistently focus on how beta cells in the pancreas work, including as they relate to the incretin system," Dr. Reddy said. New and evolving therapies might require a better understanding of the pathophysiology of diabetes, according to the roundtable's analysis.

The surveyors contacted 406 primary care physicians who treat patients with type 2 diabetes as well as 784 adults diagnosed with the illness.