Losing Ground on Diabetes Control

Would it be too strong to call this one of the biggest public health failures of the 21st century? We ask this about diabetes control because it appears to be out of control. After a decade of better control at the turn of the century, key markers of health in people living with diabetes have now turned down, according to a new analysis in the New England Journal of Medicine. Carefully choosing her words, senior author Elizabeth Selvin says:

“These are concerning findings. There has been a real decline in glycemic control from a decade ago, and overall, only a small proportion of people with diabetes are simultaneously meeting the key goals of glycemic control, blood pressure control, and control of high cholesterol.”

National Trends in Risk Markers

Selvin and her colleagues examined data from NHANES from 1999 through 2018. In fact, things improved in the first decade of this century. Until about 2007, the portion of people with diabetes with good control of their blood sugar went up. The same was true for their blood pressure and lipid levels.

But then things turned south. Glycemic and blood pressure control actually declined. Lipid control stalled out. Worse, the portion of patients with all three under control went down.

Long-Term Trend in Complications

Selvin also authored a study of the 30 year trend in complications from diabetes. She found encouraging reductions in signs of kidney disease in diabetes patients over this time period. However, she noted that “the overall burden of complications around the time of the diagnosis remains high.”

Furthermore, we note that rates of heart disease in this analysis did not improve significantly. Mainly, this was because the most recent data turned in a negative direction.

Why?

All we have is speculation to reflect on why this is happening. One factor is a signal that medical management of these patients has become less intensive. The use of some drugs for controlling blood sugar has tapered off recently. Some doctors eased off on clinical targets for blood sugar. In addition, the use of blood pressure drugs has plateaued. Likewise, the use of lipid-lowering drugs leveled out.

We also note that obesity prevalence has grown and public health strategies for dealing with it have been rather ineffective. With recent upticks in obesity among young people, we have no reasons to expect improvements soon.

A Failure of Health Policy?

So yes, this has all the signs of a troubling failure of public health policy. People are getting less rigorous care for diabetes. We have obesity treatment options that prevent the progression of prediabetes to diabetes and can put diabetes into remission. But utilization is pathetically low.

Meanwhile public health advocates rely upon pep talks about eating healthy and moving more to solve the problem. It’s not working. We can do better than this.

Click here for the study in NEJM and here for the study of longer-term trends. For further perspective, click here and here.

Men Operating Submarine Controls, painting by Eric Ravilious / WikiArt

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June 12, 2021