The National Diabetes Education Program (NDEP) was initiated in 1997 jointly by the National Institutes of Health and the Centers for Disease Control and Prevention to promote early diagnosis and to improve the treatment and outcomes for people with type 1 and type 2 diabetes. This partnership now involves over 200 public, voluntary, and private organizations dedicated to improving the lives of people with diabetes.

Because of the Diabetes Control and Complications Trial (DCCT) findings that improved blood glucose control markedly reduces the risk for retinopathy, nephropathy, and neuropathy, the NDEP initially focused on blood glucose control (1,2). This month, the NDEP and its partners are launching an expanded initiative to promote optimal control of lipids and blood pressure, in addition to optimal control of blood glucose.

The impact of cardiovascular disease on mortality and morbidity in people with diabetes has been known for years. Approximately two-thirds of people with diabetes die from cardiovascular disease (coronary heart disease, stroke, and other vascular diseases). Recently, data from the National Health and Nutrition Examination Survey showed that over the past 30 years there was a 27% decline in age-adjusted heart disease mortality in women without diabetes, but in women with diabetes, there was a 23% increase (3). In men without diabetes, there was a 36% decline compared with a 13% decline in men with diabetes. On a population basis, cardiovascular disease is the most costly complication of type 2 diabetes (4). The American Heart Association has officially identified diabetes as a risk factor for coronary heart disease (5).

Recent studies have provided greater understanding about the relationships between diabetes and cardiovascular disease, as well as evidence of the benefits of controlling blood lipids and blood pressure in people with diabetes. For example, the U.K. Prospective Diabetes Study (UKPDS) showed that the risk factors for coronary heart disease in type 2 diabetes were, in order of importance, increased LDL cholesterol, decreased HDL cholesterol, hypertension, hyperglycemia, and smoking (6). Dyslipidemia also contributes to the risk of renal disease. Two studies using the statin class of drugs have shown that rigorous lipid reduction therapy can reduce the risk of coronary heart disease in patients with diabetes (7,8).

Hypertension accelerates the rate of progression of diabetic renal disease. Control of blood pressure as well as glucose retards this progression (9). Lowering blood pressure in a subset of the UKPDS subjects to a mean of 144/82 mmHg reduced the risk for stroke, diabetes-related deaths, heart failure, microvascular disease, and retinopathy up to 56% (10). Other studies support the importance of blood pressure control, as well as the benefits of specific agents (11,12). ACE inhibitors provide effective first-line drug therapy for hypertension, because these agents have been shown to prevent or delay diabetes-associated renal and cardiovascular disease (9).

The evidence that the burden of diabetes can be significantly reduced by early, rigorous, therapeutic intervention is unequivocal (13). The DCCT and the UKPDS demonstrated that intensive blood glucose control for patients with type 1 and type 2 diabetes significantly reduced the risk for retinopathy, nephropathy, and neuropathy (1,6,14). Epidemiological analysis of the UKPDS data showed that for every 1% reduction in HbA1c, the relative risk for microvascular complications decreased by 37%, diabetes-related deaths by 21%, and myocardial infarction by 14% (6,14). For each 10-mmHg decrease in mean systolic blood pressure, the relative risk for microvascular complications decreased by 13%, diabetes-related deaths by 15%, and myocardial infarction by 11% (15). A recent study conducted in a staff model health maintenance organization found that a sustained reduction in HbA1c levels among adult patients with diabetes was associated with significant cost savings within 1 to 2 years of improvement (16).

At least two-thirds of people with type 2 diabetes are overweight (17). An excess of calories, a high-fat diet that yields positive energy balance, and a sedentary lifestyle all contribute to obesity and type 2 diabetes (18). A prospective 12-year study of 4,970 overweight people with type 2 diabetes found that intentional weight loss was associated with a 25% reduction in total mortality (19). In summary, these studies show that rigorous management of diabetes is both efficacious and cost effective.

A proactive management plan for the control of glycemia, lipid levels, and hypertension should have defined goals and targets and should meet accepted clinical guidelines (20). Optimal control of blood glucose, lipids, and blood pressure usually requires regular physical activity and a meal plan designed to lower blood glucose and dietary sodium, thus altering lipid patterns and inducing weight loss. Lipid-lowering drugs, antihypertensive drugs, and blood glucose–lowering drugs are necessary if the response to altered food intake and exercise is inadequate.

The NDEP’s messages, strategies, and tactics are science-based and consistent with the American Diabetes Association (ADA) and other national guidelines, as well as national outcome-focused programs, such as the Diabetes Quality Improvement Program, and they are designed to improve health care provider practice and patient outcomes. To reduce the gap between current and desired patient outcomes, the NDEP initiative will assist health care providers and people with diabetes to:

  • practice goal-oriented management of blood glucose, lipids, and blood pressure to help prevent or delay diabetes complications;

  • ensure that people with diabetes receive diabetes self-management education, including self-monitoring of blood glucose as necessary;

  • ensure proper food intake and physical activity to help achieve target values, including body weight;

  • use the HbA1c test for monitoring blood glucose control and for guiding therapy to achieve blood glucose target levels;

  • use combination drug therapy as necessary to achieve and maintain target values;

  • use a coordinated team approach to patient care.

This initiative will complement the activities of other diabetes organizations. The NDEP has enlisted the support of the ADA and other key diabetes organizations representing diabetes specialists, primary care providers, and other health care professionals. Voluntary groups and organizations focused on consumer needs will also contribute to this initiative. These efforts present an excellent opportunity for all health care professionals who are interested in diabetes care to lead the way in promoting the control of blood glucose, lipids, and blood pressure to other provider groups and their diabetic patients. Using NDEP or partner materials and resources, diabetes care providers can play a major role in improving patient outcomes by disseminating consistent action-oriented messages regarding diabetes control, conducting awareness and education activities for other health care providers and people with diabetes, disseminating educational tools and resources, and promoting policies and health system improvements to support comprehensive diabetes care. For information about the program, visit http://ndep.nih.gov. To order materials, call 1-800-438-5383.

1.
Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.
New Engl J Med
329
:
977
–986,
1993
2.
The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group: Retinopathy and nephropathy in patients with type 1 diabetes four years after a trial of intensive therapy.
New Engl J Med
342
:
381
–389,
2000
3.
Gu K, Cowie CC, Harris MI: Diabetes and decline in heart disease mortality in US adults.
JAMA
281
:
1291
–1297,
1999
4.
Brown JB, Pedula KL, Bakst AW: The progressive cost of complications in type 2 diabetes mellitus.
Arch Intern Med
159
:
1873
–1880,
1999
5.
Grundy SM, Benjamin IJ, Burke GL, Chait A, Eckel RH, Howard BV, Mitch W, Smith SC, Sowers JR: Diabetes and cardiovascular disease: a statement for healthcare professionals from the American Heart Association.
Circulation
100
:
1134
–1146,
1999
6.
United Kingdom Prospective Diabetes Study Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).
Lancet
352
:
837
–853,
1998
7.
Haffner SM: Management of dyslipidemia in adults with diabetes.
Diabetes Care
21
:
160
–178,
1998
8.
Goldberg RB, Mellies MJ, Sacks FM, Moye LA, Howard BV, Howard WJ, Davis BR, Cole TG, Pfeffer MA, Braunwald E: Cardiovascular events and their reduction with pravastatin in diabetic and glucose-intolerant myocardial infarction survivors with average cholesterol levels: subgroup analyses in the cholesterol and recurrent events (CARE) trial.
Circulation
98
:
2513
–2519,
1998
9.
Nielsen FS, Rossing P, Gall MA, Skott P, Smidt UM, Parving HH: Impact of lisinopril and atenolol on kidney function in hypertensive NIDDM subjects with diabetic nephropathy.
Diabetes
43
:
1108
–1113,
1994
10.
UK Prospective Diabetes Study (UKPDS) Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38.
BMJ
317
:
703
–713,
1998
11.
Hansson L: The Hypertension Optimal Treatment study and the importance of lowering blood pressure.
J Hypertens
17 (
Suppl. 1
):
S9
–S13,
1999
12.
Heart Outcomes Prevention Evaluation Study Investigators: Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and the MICRO-HOPE substudy.
Lancet
355
:
253
–259,
2000
13.
Roman SH, Harris MI: Management of diabetes mellitus from a public health perspective.
Endocrinol Metab Clin North Am
26
:
443
–474,
1997
14.
Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR: Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study.
BMJ
321
:
405
–412,
2000
15.
Adler AI, Stratton IM, Neil HA, Yudkin JS, Matthews DR, Cull CA, Wright AD, Turner RC, Holman RR: Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study.
BMJ
321
:
412
–419,
2000
16.
Wagner EH, Sandhu N, Newton KM, McCulloch DK, Grothaus LC: Effect of improved glycemic control on health care costs and utilization.
JAMA
285
:
182
–189,
2001
17.
Pi-Sunyer FX: Health implications of obesity.
Am J Clin Nutr
53 (
Suppl. 6
):
1595S
–1603S,
1991
18.
Marshall S, Garvey WT, Traxinger RR: New insights into the metabolic regulation of insulin action and insulin resistance: role of glucose and amino acids.
FASEB J
5
:
3031
–3036,
1991
19.
Williamson DF, Thompson TJ, Thun M, Flanders D, Pamuk E, Byers T: Intentional weight loss and mortality among overweight individuals with diabetes.
Diabetes Care
23
:
1499
–1504,
2000
20.
American Diabetes Association: Standards of medical care for patients with diabetes mellitus.
Diabetes Care
24 (
Suppl. 1
):
33
–61,
2001

Address correspondence to Charles M. Clark Jr., Regenstrief Institute for Health Care, 1001 W. 10th St., Indianapolis, Indiana 46202. E-mail: chclark@iupui.edu.