Despite the enormous amount of money poured into the system, the diabetes care outcome in the Unites States remain dramatically UNCHANGED over the years. There has been an onslaught of newer and newer and combined medications, but they have failed to make a great impact in the measured outcomes.
| Patiens≥ 40 years old | HbA1c < 7.0% | 49% | National Health and Nutrition Examination Survey (NHANES), 1999-2004 [30] |
| Adults (18-75 years old) with Medicaid, Medicare, or Commercial Insurance | HbA1c < 7.0% Medicaid Medicare Commercial | 30% 46% 42% | Health Plan Employer Data and Information Set (HEDIS), 2006 [31] |
| American Indians and Alaska Natives | HbA1c < 7.0% | 31% | Indian Health Service, Clinical Reporting System, 2006 [32] |
Why is this? Why this disparity?
Let us look at from an Anthropological point of view.
The images in this article was part of a presentation by a Professor-Pawn, an academic physician in the employ of a drug company, who in the guise of providing scientific, evidence based medical care, subtly or not so subtly promotes the medications of the company he is allied with. I have taken some of the slides to provide an anthropological point of view which of course was completely neglected by the presenter.
One fact many presenters or writers of the articles would begin their story is by telling us what will happen in the future. It is a well known trick used by media of totalitarian governments where the news is about what will happen in the future, not what has happened recently.
If a person is projecting a tragedy for which he has no understanding, he is also confessing that he has no knowledge of why we are where we are: Why is Obesity and DM type 2 are increasing relentlessly regardless of the newer treatments and methods and innovations? An American Indian lobbyist once drew the graph of the number of American Indian patients with Diabetes and the number of Providers and auxiliary people available for diabetes care and there was a good correlation between the increasing number of Diabetes Providers (of all sorts, Doctors, Nurses, Nurse Practitioners, Physician Assistants. Nutritionists, Physiotherapist, the so called Exercise specialists, psychologists) and the increasing incidence of DM type 2.
The Indian lobbyist sarcastically asked the professionals present: Are you the CAUSE of the epidemic of Diabetes among the Indians?
The figures showed that despite the increase in the number of providers the rise in Type 2 Diabetes progresses unabated.
So people would say, DM is increasing all over the world but no one spends time or effort to find out WHY it is so.
This fundamental lack, this manner of questioning, common among Anthropologists and less so among the Physician scientists perhaps underlies the differences in prevalence, lack of success in treatment. How can we succeed in treatment if we do not know what causes the disease and a social disease such as Diabetes type 2 cannot be cured or treated well with just medications alone, and what is promoted in journals and conferences? Medications and new treatments.
Physicians want to know WHAT is happening and an Anthropologist? WHY it is happening, and the explanation is a QUALITATIVE one, but the Doctors and scientists are not satisfied without statistics and numbers and certainty.
One thing is certain, in 2018 70 per cent of the Americans are overweight of which 40 per cent are Obese. The scientists and Doctors have known it over thirty years and none of their interventions have stopped this onward march. Perhaps they should allow other social players to have a word, including Anthropologists, Psychologists and people with expertise outside the strict biomedical interpretation of Socially causes symptoms such as Obesity and Diseases such as Diabetes Type 2.
The presenters at these meetings have always a quasi-real person, here it is Brittany, a 37 year old African American woman with 4 children.
Medspeak Grade 2 Obesity? If she is 5 ft 5 inches tall, she has to be 228 lbs to have a BMI of 38 but here it only says her BMI was greater than 38? so what was her weight? How does a OBESE person with all the metabolic dysfunctions react to medications? What else need to be done for this poor lady?
A little social history is mentioned but never again brought up as if the Social aspect of her life is not that important in the control of her Diabetes.
Works at a call centre for Insurance company? Income? immediately that puts her in a lower income status.
Nutrition: Fast Food and VENDING MACHINES.. oh my god, what this lady needs is not the latest GLP 1 RA but FOOD, real FOOD.
No MEDICATIONS HAVE BEEN INVENTED THAT WOULD PREVENT THE DAMAGE TO THE TYPE 2 DM (OR CAUSING IT) DONE BY FAST FOOD OR WORSE STILL VENDING MACHINE FOOD AVAILABLE TO A 37 YEAR OLD AFRICAN AMERICAN MOTHER OF 4 WHO WORKS AT A CALL CENTRE!
I am almost certain that this lady cannot afford to pay for all the medications she is on, let alone the addition of a more expensive GLP 1 RA which on the average cost around 750 USD per month!
so is it surprising that only 1/3 of the patients who are prescribed these newer medications actually take them? Do you wonder why the poor people in America have the lowest Diabetes control rate? Poverty, Obesity, Lack of Food, Anxiety about medications, anxiety about payment and access to doctors, the list goes ..and do you think they can promote some medications to overcome these problems and their effects on the wellbeing of the person including his blood sugar control?
It is well known that when patients are given intensive therapy within the year of their diagnosis. their rates of all complications are dramatically different from those who did not receive the intensive therapy. It is precisely at this period that these expensive medications are not introduced and it is best done by Metformin, Insulin and Diabetes Education. Given their importance in equal amounts I believe that most Type 2 Diabetes patients newly diagnosed can be controlled, if extraneous conditions do not exist: such as Poverty, Food Desert, Alcohol Abuse. I do feel that the efforts of poverty can be ameliorated by continuous education given by Peer Educators and Diabetes Educators. Other methods of Insulin delivery begun earlier on in the course of the disease is very effective as well.
As we have seen, 70 per cent or at least 2/3 of patients with Type 2 Diabetes are above range of control and how much further control can you expect from these new expensive medications ?
Their effects are 2/3 of a One percent of Hgb A1c reduction! which is nothing when the majority of patients you are seeing are at least 2 to 3 percentage points above the desired value. There is a modest weight loss with these medications and now the drug companies are harping on the 5 lb. weight loss!
Now the drug companies and their professor-pawns are promoting combination drugs that include INSULIN as well. It does not take much intelligence to see that the reductions in HgbA1c is due to the insulin as the GLP1RA are known to reduce HgbA1c only by 2/3 of a one percent and insulin is known to reduce the A1c by larger degree. If the Insulin delivery systems are compared, any system that mimics a natural state (such as a closed loop system now widely available) can offer a reduction of 3-4 percentage in a short period of time.
IT IS WELL KNOWN THAT BASAL INSULIN ALONE IS ABLE TO ACHIEVE TARGET HbA1c IN 50 %OF THE PATIENTS.
At all times, education must be continued. It is calculated that a Type 2 Diabetes patient may get 15 min of his doctors time four times a year, adding to one hour whereas the 5000 hours he or she is on their own, looking for ways and advice and tricks to manage their lives of which Type 2 Diabetes plays a part.
To me the most important player in the team that looks after a Type 2 Diabetes patient is the Diabetes Educator, whether a CDE or RD or a Peer Educator. All others are accessories.
In the patient presented, the 37 year old African American woman with four children who works at a call centre for Insurance company is persuaded to take one of the newer medications, while noting that she has no time to see a CDE.
I ask my doctor friends, what is more important, time spent with a CDE or yet another medication?
The gist of the presentation from which these slides were culled was given by a Clinical Professor to a group of practising Family Physicians. As my good friend Dr MW pointed out, there is a general assumption that FPs are not as smart but it is far from the truth.
I have the great honour to work with wonderful MD FPs in the tribes of Indians I am associated with, Dr MM in Nebraska and Dr RE in Florida. and my own friend Dr MW is a great example of an erudite and curious FP! also Dr.Jim the flying FP of S. Dakota!
As I work in a Social Medicine set up (not Fee for Service), our modest success is due to the fact that :
Those of us who are involved in the care of the patients are genuinely interested in the welfare of the patient with wonderful follow up of the patients through social contacts and with us living in the same villages where the Indians live.
There is continuous health education. As MS our CDE would say, every encounter with a patient is a chance to educate. We have experimented with Peer Educators, an idea borrowed from MoPoTsyo in Cambodia (run extremely well by our friend MVP) and it has been a success.
With the blessing of the CEO of the Health Centre, we were able to institute a Insulin Pump system and invited people to participate in it. Thus many patients were included in the usage of Insulin Pumps from the early stages, and the results are fantastic.
It reminds me of an adage I remember from my childhood: Where there is a will, there's a way..
As a Physician, I learned to side with the winning side, that was of the Diabetes Educators. I have worked with excellent Diabetes Educators, including the current Star of my Diabetes world, ABB of the Omaha Tribe and also MS, CP, DBS.. from my past lives as well as AVS and Dr.S from Florida.
Millions of people in the USA and around the world are struggling with this disease, a social disease brought on by forces beyond the control of these patients, and our duty is to help their QUALITY OF LIFE rather than preach to them about LIFESTYLE changes.
To the countless dedicated FPs and Diabetes Educators, I take my hat off to them!
