It Can Be Done

Editor’s comment: After reading Dr. Hood’s results in an abstract for the 2003 American Diabetes Association (ADA) meeting, I invited him to write this letter. It serves to remind clinicians caring for diabetic patients that it can be done and to stimulate us to keep trying and to not be satisfied with less than the ADA’s evidence-based goals.

The American Diabetes Association (ADA) has set standards of care that include various metabolic targets that are founded on evidenced-based medicine (1). Despite the widespread dissemination of these targets, many patients fail to obtain adequate control. There have been progressive developments in the understanding of type 2 diabetes and its attendant risk for both microvascular and macrovascular complications. With the host of new treatments available to the diabetes care team, the patient has an unprecedented opportunity to adequately control risk factors. Despite this exciting state of affairs, many clinicians are not of the opinion that these targets can routinely be met in clinical practice. One is hard pressed to find published data documenting success in achieving these goals. The purpose of this letter is to demonstrate that many of the goals espoused by the ADA may in fact be achievable in the majority of patients with type 2 diabetes.

The following is a cross-sectional study of the 452 active patients seen for type 2 diabetes in a community-based endocrine practice during the months of May through July 2003. These patients had their first visit at least 6 months prior and at least one other visit during the previous 6 months. Patients were referred for comprehensive diabetes education at the time of initial evaluation with follow-up education as needed. Data are reported as means ± SD (range). The average age was 64.9 ± 13.9 (11.4–92.4) years, and duration of diabetes was 12.2 ± 8.9 (1.0–51.0) years. Women represented 57.7%, Caucasians 83.4%, and African Americans 13.9%. The average BMI was 34.1 ± 8.1 kg/m² (19.6–78.0), whereas waist circumference was 42.3 ± 6.6 (27.0–65.3) inches in women and 44.0 ± 7.2 (31.0–75.5) inches in men.

HbA_1c was 6.38 ± 0.90% (4.9–11.9) with 85.4% of subjects falling in the <7.0% range. The systolic blood pressure was 124.0 ± 15.0 mmHg (80–210) with 75.4% of subjects falling in the ≤130-mmHg range. Diastolic blood pressure was 68.2 ± 10.7 mmHg (30–100) with 92.7% of subjects falling in the ≤80-mmHg range. LDL cholesterol was 81.2 ± 25.0 mg/dl (27.0–179.7) with 81.8% of subjects falling in the <100-mg/dl range. Triglycerides were 158.3 ± 129.0 mg/dl (20–2,046) with 59.3% of subjects falling in the <150-mg/dl range. HDL cholesterol in women was 54.0 ± 14.5 mg/dl (25.2–113.0) with 56.2% of subjects falling in the >50-mg/dl range. HDL cholesterol in men was 45.0 ± 11.4 mg/dl (25.9–95.0) with 59.2% of subjects falling in the >40-mg/dl range. Antiplatelet therapy was prescribed to 94.2% of patients aged ≥30 years in whom such therapy was not contraindicated.

Goals that were readily attainable included antiplatelet therapy, LDL cholesterol, blood pressure, and HbA_1c. More problematic goals included triglycerides and HDL cholesterol. Polypharmacy was common, with an average of 5.1 ± 2.0 (0–11) medications being used to treat glucose, blood pressure, and lipids. The multiplicity of risk factors, the difficulty of long-term lifestyle changes, the complexity and cost of pharmacologic regimens, and the cost, time, and discomfort of self-monitoring of blood glucose all contribute to the difficulty in managing this condition. The fact remains, however, that many of these goals are readily attainable if all of the tools at our disposal are used in an aggressive and systematic fashion that blends science and clinical judgment. The clinician’s belief in the importance of these goals and an implacable commitment to pursue them (with aggressive polypharmacy, if necessary) are essential.