COMMENTARY

A New Diabetes Diagnosis? Maybe We Could Have Addressed This Earlier

Richard M. Plotzker, MD

Disclosures

October 18, 2016

From time to time, the chief resident assigns me to case conference, where one or two residents will present a case with unusual findings or branch points to be decided. As we discuss the patient at hand, it has been my custom to throw them a few curveballs that can be applied to other people they see, either in the hospital or on their half-day weekly outpatient sessions. Two sessions back, they thought they would be talking about hyperosmolar coma. A woman with severe hyperglycemia but no ketosis presented to the intensive care unit (ICU). She came to the medical ward shortly thereafter with some questions of a minor nature on what to do next.

Richard M. Plotzker, MD

But instead of what to do next (ie, adjust her insulin and stage her for complications of newly identified type 2 diabetes), her record prompted a more provocative question about what took place 2 years earlier, when she spent a few days in the hospital to have her appendix removed. Having personally seen her myself while she was still in the ICU, I asked the presenting resident if the patient was really a new diabetic or one who was essentially neglected at the earliest stages. Sure enough, the house staff had inherited her from the ICU and, not having read the old record other than some summaries, did not know that her glucose exceeded 200 mg/dL on several occasions during the last admission. The people taking care of her had monitored her bedside glucoses and A1c, which was 6.7%, but the summaries made no mention of hyperglycemia or diabetes. To be fair, she had some respiratory problems and received some acute glucocorticoids for them, which raised the glucose level from baseline. However, it was not mentioned to subsequent doctors, and she never sought any regularly scheduled medical care until overt clinical diabetes became obvious. Even then, she did not seek medical attention until symptoms became extreme. A note in the discharge instructions to bring this to her or her physician's attention might have done her considerable benefit. But, without it, she did not seek primary care after the surgery.

Of note, the new physicians and handful of medical students were mostly unaware of prior studies that were done to limit the progression of hyperglycemia from prediabetes to clinical diabetes. These dozen or so efforts had their moment of fame in the early part of the last decade, with an American study[1] using lifestyle modification and metformin and a Finnish study[2] with a lifestyle protocol the subjects of much commentary and intrigue about what seemed possible. However, a dozen years of exam room encounters later, many patients with diabetes are still coming in for specialty care, many with records showing an interval of not-quite-normal glucose metabolism but not-quite-clinical diabetes. Despite the success and consistency of these trials that were done all over the world and that spanned many regional diets, they remain in obscurity and not a part of the medical student's clinical curriculum.

In reality, you can send patients to dietitians incessantly and chase them around the track while under professional observation if you have a research grant to pay the people needed to do this. If you need a preauthorization from a Cadillac health plan or Medicaid, the insurance clerk will take that request, turn it into a paper airplane, and glide it into the wastebasket. Payout for test strips and hypoglycemic agents may not be a better buy, but at least it's on formulary. Unfortunately, the effective interventions are labor intensive and require motivated medical volunteers to succeed.

More recent attempts at diabetes prevention have tried to bypass the obstacles with some measure of success. Most medical volunteers are willing to take a pill and show up for lab testing, as are most real office patients. A multicenter study[3] showed a reduction in the rate of progression to diabetes (from 7.6% to 2.1%) by giving pioglitazone for about 2 years compared with placebo. That study is now 5 years post-publication, but we are still not doing it, even though it is easy and effective. Unfortunately, you have to deal with the side effects of the medicine, which in the study included a weight gain of 10 lb and an edema rate of about 13%, not to mention the risk for bladder carcinoma. Those adverse elements may be acceptable for someone with insulin-resistant hyperglycemia but probably not for people who apparently have little wrong with them except their fasting glucose and their weight.

Interventions that are too difficult or too expensive are no good, and adverse effects limit even effective implementation. More recently, a British study[4] attempted to pursue the quest for easy and safe intervention with some success. A large "Let's Prevent Diabetes Trial" essentially failed when all participants were analyzed. But, as in most large cohorts, some people did better than others. The researchers looked at their data retrospectively[5] to determine who might succeed in their program, which did not require an unreasonable amount of resources beyond what an office practice could provide. They offered as part of their program a series of educational sessions and an update after 2 years of the 3-year study. As Woody Allen noted some time ago, "Showing up is 80% of life." Attendance in the program was voluntary. About 77% of the participants attended the initial session, with attendance tailing off precipitously afterwards. Attendance at more than one session was 55% and complete attendance for all sessions was only 29%. However, the attendance of more than one class correlated with a lower rate of progression from glucose intolerance to diabetes.

Which of the participants were more engaged? The more loyal and, therefore, more successful participants were older, nonsmokers, and less heavy. It seems that the people who are most likely to control their glucose already have an element of maturity and some independent commitment to their own health. Attending the classes was just one more effort for them that paid off.

Maybe we should revisit the diabetes prevention trials of the previous era, where the people who put forth the most effort and took best advantage of the resources offered to them had the best results. Prevention of diabetes can be made easy enough for people to do, but it will never be passive.

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