Diabetes mellitus (DM) is a significant, chronic disorder that is heterogeneous in nature and is characterized by elevated blood sugar levels and abnormal carbohydrate, protein, and fat metabolism. It is categorized into 2 major types: Type 1, or insulin-dependent, accounts for approximately 10% of DM cases, wherein destruction of islet cells results in eventual failure of insulin secretion. Insulin injections are necessary in these patients to sustain life. Type 2, or non-insulin-dependent diabetes mellitus (NIDDM), accounts for approximately 90% of DM cases and is associated with a defect in insulin secretion as well as a syndrome of insulin resistance. Insulin resistance occurs in most type 2 patients; blood glucose levels are elevated and, in addition, blood pressure is high, blood lipids are increased, and patients have abdominal obesity. Type 2 patients are most often treated with diet, exercise, and oral agents; however, approximately 45% of these patients are currently using insulin as part of their treatment regimen. Additionally, diabetes results in an increased risk of cardiovascular disease.

A National Concern

As baby boomers reach the middle years of their lives, the number of patients with diabetes is expected to increase dramatically. Currently, there are more than 16 million people with diabetes in the United States and 120 million worldwide. Approximately 6 million US residents who have diabetes have not yet been diagnosed. Diabetes mellitus accounts for 7.2% of hospitalizations, while approximately 17% of patients in nursing homes have diabetes. More than $100 billion is spent on diabetes in the United States each year, and approximately 40% of those funds are allocated for inpatient hospital care. Diabetics are hospitalized 1.5 to 3 times more often than nondiabetics and have a two- to fourfold greater risk of atherosclerotic disease.

When blood sugar levels are consistently elevated, long-term complications of diabetes result. Patients with diabetes have the highest incidence of adult blindness, chronic renal failure, and atraumatic amputations. Diabetes also leads to heart disease, with up to 80% of diabetes patients dying from heart-related problems.1 Diabetes causes a major drain on the healthcare system and, even though only 6% of the total US population has diabetes, it accounts for 1 in every 7 healthcare dollars spent. Moreover, diabetes has become the fourth leading cause of death by disease and the leading cause of newly diagnosed kidney disease and impotence. Minorities have a much higher incidence of diabetes, with African-Americans having double the average incidence, Spanish-speaking populations triple, and Native Americans quadruple.

The Diabetes Control and Complications Trial (DCCT) has proven that intensifying insulin regimens decreases chronic complications by 60% overall. The negative consequences of poor glucose management are significant and include retinopathy, nephropathy, neuropathy, and exacerbated cardiovascular disease. A second major study which was done over a 20-year period in type 2 patients called the United Kingdom Prospective Diabetes Study (UKPDS) also proved that metabolic control matters and that every effort to normalize blood glucose and blood pressure should be made to reduce chronic diabetes complications.

Results of the DCCT and UKPDS studies have proved once and for all that metabolic control really matters, and this should force changes in the diabetes healthcare system to intensify treatment options and bring average blood sugar levels closer to normal.

National guidelines are available. The Standards of Diabetes Care of the American Diabetes Association (ADA) have been published. The Health Employer Data and Information Set (HEDIS) guidelines for managed care organizations also focus on improving diabetes care. These guidelines have intensified the interest in improving the outcomes of diabetes care substantially.

Importance of Self-Monitoring

Successful treatment of diabetes requires an educated patient who balances diet, exercise, and drug therapy to achieve near-normalization of blood glucose. Daily self-monitoring of blood glucose (SMBG) is essential to determine if the treatment guidelines are followed. Diabetic patients should also have a hemoglobin (Hb)A1C test performed at least twice a year. This provides data about how well the patient has kept blood glucose levels near-normal over the previous 12 to 16 weeks. Blood pressure and cholesterol should also be monitored and normalized. Achievement of ADA Guidelines through greater treatment intensity will result in a better daily quality of life with fewer acute and chronic complications.