CLINICAL COMMENTARY

New challenges in caring for diabetic patients

Primary care physicians can get caught in the middle

Robert Spanheimer, MD

VOL 116 / NO 1 / JULY 2004 / POSTGRADUATE MEDICINE

The author discloses no financial interests in this article and no unlabeled uses of any product mentioned.

Spanheimer R. New challenges in caring for diabetic patients: primary care physicians can get caught in the middle. Postgrad Med 2004;116(1):51-4

Recently I had the opportunity to speak with five primary care physicians about goals in caring for patients with diabetes. During the roundtable discussion, I mentioned the new recommendation to lower the limit of fasting blood glucose from 110 mg/dL (6.12 mmol/L) to 100 mg/dL (5.55 mmol/L) for diagnosis of impaired fasting glucose (one of the criteria for diagnosis of metabolic syndrome). All of the physicians became clearly upset, and the consensus was that this requirement would further increase the number of abnormal test results to include "almost everybody."

Their response dampened my enthusiasm for the recommendation's potential to provide earlier diagnosis, until I realized that they reacted so strongly because the guideline would significantly increase their workload. They would be caught in the middle between the high number of patients diagnosed with impaired fasting glucose and the specialists who insist that primary care physicians "do something" for these patients.

The number of US patients who have diabetes mellitus or metabolic syndrome is increasing at an alarming rate--especially in the nation's youth--and this rise is not due to changing the criteria for diagnosis. The obvious consequence of the growing number of younger patients being affected is the development of complications at an earlier age. Five criteria are used to diagnose metabolic syndrome, but the driving force behind the higher rates of both this condition and diabetes is obesity.

Obesity is not just a problem in the United States. As per capita income increases in any given country, obesity follows, with the rate of diabetes rising 4 to 6 years later. There are many potential reasons for this increase. They range from the advent of the electronic age (the average amount of time persons spend watching television or using a computer is between 4 and 6 hours per day) to reduced physical activity (people are driving more and walking less) to improved agricultural techniques (farmers can produce 4,200 calories per person for daily consumption, but we need only 1,600 to 1,800 calories daily to maintain our weight).

Many other forces contribute to the problem, including corporate America (eg, advertising and promoting poor eating habits), schools (eg, not teaching healthy lifestyle approaches, selling snacks to students to raise money), and parents (eg, providing money for snacks, setting poor examples through their own lifestyle). The bottom line is that many factors are to blame, but that does not absolve our responsibility, as a society, to teach members of the next generation how to take care of themselves. The health consequences of failing that responsibility are enormous, with projected rates of diabetes and heart disease in young adults aged 20 to 30 that will stress our healthcare system to the limits in both cost and capacity.

Burden of care

Physicians are further caught in the middle between patients trying to find someone or something to blame for their condition and the diseases that result from patients' poor health habits. The overwhelming burden of caring for these patients falls on the primary care physician: Only 8% of diabetic patients are seen by an endocrinologist. What unites primary care physicians and other specialists is the common goal of reducing diabetic complications, primarily cardiovascular disease. Furthermore, we physicians all recognize that early and aggressive treatment offers our best chance for success.

Although lifestyle changes have been shown to help reduce morbidity and mortality, a culture of failure has developed nonetheless, and primary care physicians have to deal with day-to-day resistance from patients to implement necessary changes. Physicians are then compelled to recommend medications to avoid chronic complications from disease and are thus labeled as pill pushers.

Meanwhile, patients often take many "natural" supplements, which physicians may perceive as indicative of a lack of trust in their recommendations. This is very frustrating for physicians who deal with an increasing number of patients on a clear track to metabolic meltdown. Why patients prefer to take 5 to 20 different herbal or natural preparations rather than one prescription from their doctor baffles me, but it may represent the power of advertising. Many physicians spend a lot of time explaining the reasons for prescription medications, yet some patients would rather believe that a higher intake of nuts and chocolate will reduce their chances of diabetes (as was recently published in some newspapers).

Finally, primary care physicians are well aware that patients who have diabetes or metabolic syndrome at an early age will have a high rate of complications because of the long duration of their condition. Therefore, these patients must use medications and adhere to goals recommended for older patients--treatment approaches that have not yet proved successful in members of their age-group.

Patient accountability

Potential solutions to this growing problem include active involvement of patients in their treatment. Patients who want their physician to explain their weight gain are seeking a simple solution, but they need to realize that they are ultimately responsible for their health. I often ask patients at their appointments how many calories they burned that day. Universally, they do not know, and I compare calories that are consumed and not expended to a full tank of gasoline in a car that is not driven. It can be helpful for physicians to set goals for patients and offer help in achieving these goals, rather than be put in a position of defending a healthy lifestyle that patients view as difficult or impossible.

I often write a prescription for 150 minutes of physical activity a week and the loss of 10% of body weight and remark that no medication can provide as much benefit to a patient's health as this prescription can. To reward patients, I make it a point to reduce a medication for every 20 lb of weight they lose, further involving them in their care and making it worthwhile for them to succeed.

In the long run, patients need to understand that not only must they take responsibility for their own health, they need to set an example for their family--especially their children. Simply telling children how to eat and exercise is not good enough; parents must show them how to take care of themselves.

Finally, early referral to an endocrinologist for one or two visits to assess metabolic risk provides backup for the primary care physician. The common tie between primary care physicians and endocrinologists should be the early recognition of high-risk patients, especially in regard to diabetes and cardiovascular disease. Macrovascular complications cause death in 80% of patients with diabetes. At the time their diabetes is diagnosed, 50% of patients have heart disease (often undiagnosed), which indicates early involvement of abnormal glucose metabolism with the cardiovascular system.

Despite more stringent guidelines for diagnosis and the availability of better medications, cardiovascular disease in patients with diabetes has increased in the last decade. More increases can be expected unless we act. Whether the origin of this current epidemic is more cultural or medical, we must continuously strive to understand metabolic diseases and implement proven guidelines to help our patients avoid long-term health consequences.

The two symposium articles that precede this commentary address the growing number of patients at high risk for cardiovascular disease associated with abnormalities in glucose and lipid metabolism. Metabolic syndrome is recognized as the major contributor to the high incidence of metabolic cardiovascular disease. Dr Gregory Doelle reviews the clinical picture of metabolic syndrome as well as evidence linking the syndrome to accelerated cardiovascular disease. Dr William L. Sivitz discusses the pathogenesis of insulin resistance, techniques for assessing insulin sensitivity in the research setting, and the clinical implications of insulin resistance in affected patients.

Understanding the pathophysiologic basis of insulin resistance will likely provide new therapeutic approaches to reduce the high risk of cardiovascular disease. In the meantime, we physicians must remain vigilant in explaining to our patients the risks associated with poor lifestyle habits as we encourage them to take responsibility for their health.

Dr Spanheimer, coordinator of this symposium, is acting chief of endocrinology and associate professor, department of medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, and staff physician, Veterans Affairs Medical Center, Iowa City. Correspondence: Robert Spanheimer, MD, Division of Endocrinology, VA Medical Center, East-17, Hwy 6, Iowa City, IA 52246. E-mail: robert-spanheimer@uiowa.edu.

Symposium Index

• THE CLINICAL PICTURE OF METABOLIC SYNDROME: An update on this complex of conditions and risk factors. By Gregory C. Doelle, MD
• UNDERSTANDING INSULIN RESISTANCE: What are the clinical implications? By William I. Sivitz, MD
• Clinical Commentary. NEW CHALLENGES IN CARING FOR DIABETIC PATIENTS: Primary care physicians can get caught in the middle. By Robert Spanheimer, MD

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