Experts say people with type 2 diabetes need to be sent to specialists so they can get on proper treatment plans.
Despite the number of diabetes treatment options available today, researchers are saying a significant number of patients with type 2 diabetes are not seeing any significant improvements in their blood sugar levels.
Referred to as “clinical inertia” in a recently published report funded by pharmaceutical giant Sanofi-Aventis, researchers state that “the proportion of people with type 2 diabetes who fail to achieve glycemic goals continues to rise.”
Clinical inertia is defined by a delay in treatment intensification despite a patient’s persistently high blood glucose levels.
In other words, the patient isn’t getting any healthier and their healthcare team isn’t making changes to their treatment protocol.
“Clinical inertia prolongs the duration of patients’ hyperglycemia,” explains the report, “which subsequently puts them at increased risk of diabetes-associated complications and reduced life expectancy.”
The study authors add that clinical inertia is actually the result of a complex interaction between patient, healthcare providers, and the overall healthcare system that comes with many barriers (such as the financial burdens to patients).
They add the lack of cohesive effort to help improve a patient’s health creates an even greater challenge.
One of the world’s most prescribed drugs is the oral antidiabetic diabetes (OAD) drug metformin. It has been prescribed to more than 120 million patients worldwide.
However, metformin also has one of the lowest patient adherence rates, largely due to its uncomfortable digestive side effects.
Despite this, metformin continues to be considered the “first line of defense” when prescribing a medication for patients with type 2 diabetes.
Christel Oerum, a diabetes health coach from DiabetesStrong, said the problem is far more complicated than just a lack of more effective prescriptions.
“I’ve had so many people reach out to me who were just diagnosed with type 2 diabetes,” Oerum told Healthline. “They say their primary care doctor told them to follow a diabetic diet and to start exercising. And too often, that’s the full amount of support and education they get. No wonder they aren’t seeing improvements.”
Oerum explained that metformin works by reducing the amount of glucose a patient’s liver dumps into the bloodstream. However, it can’t compensate for a highly processed, carbohydrate-laden diet.
When it comes to better education around nutrition, Oerum fears the common medical advice to “eat healthy” is so vague that it can actually be dangerous.
“Newly diagnosed patients with diabetes leave their doctor’s office thinking they need to eat less sugar in order to eat healthy, but there was no conversation about carbohydrates in general, or how even a bowl of brown rice can severely raise your blood sugar,” she said. “These patients think they’re avoiding sugar, but by the time they come to me, they’re eating crackers like crazy and have no idea that crackers are pure starch, raising their blood sugar.”
Oerum added that nuts and avocados are another example of how the advice to “eat healthy” can backfire, because snacking on nutrient-dense nuts all afternoon can easily add up to 800 calories and 70 grams of fat.
“These newly diagnosed patients need very specific guidelines. If I start talking to them about macronutrients, their eyes glaze over,” said Oerum. “So, I take it down a notch by talking about limiting breads, avoiding processed starches like crackers or starchy vegetables like potatoes, and focusing on a specific list of less-starchy whole foods.”
Oerum says primary care doctors are often the physician a type 2 patient sees because most hospitals simply don’t have enough endocrinologists to see patients with type 2 diabetes.
She says these primary care physicians need to do a better job of providing patients with resources, such as nutrition pamphlets from the American Diabetes Association, as well as the hundreds of online resources for diabetes education.
“Too often, it seems like doctors don’t bother to help their patients learn more after their appointment,” she said. “When a patient gets a diagnosis like that, they simply aren’t going to remember the onslaught of information told to them in the doctor’s office.”
Oerum’s concerns about how exercise is discussed during those early appointments are no different.
“So many people think exercising means jogging five miles. And if they can’t do that, they just give up,” she explained. “Walking is such good exercise, and most people can walk. Even if it’s 15 or 30 minutes a day, it’s going to help lower blood sugars and lose weight.”
The issue of medication options offered to a patient with type 2 diabetes is even more complicated.
A 2016 patient survey published by the American Association of Clinical Endocrinologists reported that patients with type 2 diabetes are more willing to take action to achieve their blood glucose and HbA1c targets more quickly than their healthcare team.
Dr. George Grunberger, FACP, FACE, the survey’s co-author and founder of the Grunberger Diabetes Institute in Michigan, told Healthline that he is frustrated with how today’s healthcare system manages patients with prediabetes and type 2 diabetes.
“The vast majority of people with type 2 diabetes are never seen by a diabetes expert,” explained Grunberger. “The most common disease, affecting 30 million people in the United States, is being managed by doctors and other healthcare professionals who aren’t qualified.”
Grunberger fears that most primary care professionals aren’t actually discussing target blood glucose and HbA1c ranges with their patients. And patients aren’t getting enough education to understand why improving their blood glucose levels is so critical in the first place.
“When a patient has shoulder pain, they’ll tell their doctor, and there is a sense of urgency,” he explained. “With diabetes, nothing really hurts at first. I’ve yet to hear a patient say, ‘My blood sugar hurts. My cholesterol hurts.’ There isn’t any urgency. And telling them they need to do this series of daily things in order to prevent a complication or a stroke years from now doesn’t create urgency.”
By the time patients with type 2 diabetes do finally get a referral to a diabetes specialist like Grunberger, it’s often too late.
“Do I ever see a patient recently diagnosed with prediabetes? No,” said Grunberger. “Do I ever see patients recently diagnosed with type 2 diabetes who are managing by making changes in diet and exercise? No. Do I ever see patients who have been prescribed metformin? No.”
Grunberger says patients are finally referred to him only because the primary care doctor has run out of ideas and everything they’ve tried has failed.
That can be years after the patient’s initial diagnosis when complications such as damage to the blood vessels in their eyes and the nerves in their feet have already developed.
“I would mandate that every patient sees a qualified diabetes specialist immediately after their diagnosis,” explained Grunberger. “Then they would get a thorough diabetes education, understand why their blood glucose levels matter, and the specialist would create a plan that the patient could eventually carry out with regular visits to their primary care.”
Grunberger adds that the 5,000 diabetes specialists in the United States simply can’t take on the 30 million patients who need the standard four “diabetes checkup” appointments per year.
“I don’t think diabetes is being considered a big deal, nor is it being treated by the physician community with enough respect,” said Grunberger.
“In our 2016 patient survey, the most shocking part of the results was how frustrated the patients were with how slowly their doctors progressed their treatment,” he noted. “Doctors are assuming patients don’t want to try different medications or be more aggressive, but did they even ask their patients: What do you want to do?”
In Oerum’s experience with coaching diabetes clients, she feels that some physicians are actually contributing to patients’ fears of more aggressive treatment.
“A lot of healthcare professionals have the perception that patients with type 2 diabetes don’t want to go on medications or needles, and they’re actually reinforcing the misconception that needing a diabetes medication is ‘failure,’ which is a shame because then patients are afraid to take the drugs that could actually improve their blood sugars the most quickly, help them lose weight, and turn around their health,” she said.
Oerum added that research has clearly shown how putting some newly diagnosed patients with type 2 diabetes on insulin sooner can give their pancreas a little relief, and that actually improves its long-term ability to better produce insulin.
“I think too many doctors still start out treating all cases of type 2 diabetes with diet and exercise, and keep that strategy for far too long,” said Oerum. “And on top of that, there’s still a strong misunderstanding among some healthcare professionals that people living with diabetes are lazy. In order to provide patients with better treatment, healthcare professionals need to individualize their treatment and respect the individual.”
The study authors agree, concluding that there needs to be significantly more referrals to certified diabetes educators and supportive programs to allow for regular, patient-centered, nonjudgmental discussions that give more intellectual and emotional support to patients with type 2 diabetes.