Spotlight on the state of diabetes

From the ancient Egyptians to current pilot projects, two recent articles in the New England Journal of Medicine reviewed the history and current state of diabetes care.

In “The Past 200 Years of Diabetes, “ the author described progress in diabetes treatment from the development of insulin to modern advances such as home glucose monitoring, team-based care and bariatric surgery. However, he noted that there have been negative developments in the field as well, specifically the vast increase in type 2 diabetes incidence. “In fact, if one views diabetes from a public health and overall societal standpoint, little progress has been made toward conquering the disease during the past 200 years, and we are arguably worse off now than we were in 1812,” he wrote.

To deal with this situation, more preventive efforts need to be evaluated and implemented, according to the article. Research should be conducted on the effectiveness of trans fat elimination, restaurant calorie posting, school cafeteria menu changes and soda taxes. “Lifestyle modification will undoubtedly play a key role in the ultimate solution to the problem of diabetes, but the necessary modifications have not been easy to implement,” he added.

The other article, “What's Preventing Us from Preventing Type 2 Diabetes? “, dealt specifically with the challenge of prevention. The authors, from the National Institute of Diabetes and Digestive and Kidney Diseases, discussed why the interventions of the Diabetes Prevention Program (DPP) have not been widely implemented despite evidence that they safely and cost-effectively prevent or delay onset of type 2 diabetes.

Some progress has been made to implement the program's diet and exercise lifestyle intervention, with more than 100 sites in 25 states now providing group-based programs. However, the spread of these programs is limited because most payers, including the Centers for Medicare and Medicaid Services, do not cover such services. Improving payment for certified providers of these lifestyle interventions could prevent some cases of diabetes and improve public health, the authors concluded.

The DPP's other finding, that metformin reduced development of diabetes in overweight or obese patients with prediabetes, has not been widely implemented either. This is likely due to lack of FDA approval for this indication, and because the drug is generic, no manufacturer is likely to apply for approval unless some incentive or alternate pathway is provided, the authors said. The costs and benefits of preventing diabetes need to be assessed over a long timeline, they urged.