What Can Pharmacists Do to Improve Clinical Outcomes in Diabetes After Study Finds Glycemic Control in Adults Is Worsening?

According to the CDC’s 2020 National Diabetes Statistics Report, an estimated 34.1 million adults age 18 years and older, which represents an estimated 13% of all US adults, have diabetes.¹ Moreover, 7.3 million adults aged 18 years or older who met laboratory criteria for diabetes were not aware of or did not indicate having diabetes—also known as undiagnosed diabetes.¹ The 2020 report also notes that in 2018, an estimated 88 million adults ages 18 years and older had prediabetes. Additionally, the report mentions that between 1999 and 2016, rates of type 2 diabetes (T2DM) rose from 9.5% in 1999-2002 to 12% in 2013-2016.¹ During 2018, there were 1.5 million new cases of diagnosed diabetes, the report also states.¹ 

According to the International Diabetes Federation (IDF), an estimated 463 million adults (20-79 years) are living with diabetes and by 2045 this number will expand to 700 million.² The IDF also estimates that an estimated 374 individuals are at heightened risk of developing T2DM.² T2DM accounts for the majority of cases of diabetes and is strongly associated with diet and lifestyle factors.^2,3 Rates of diabetes continue to soar due to various factors such as obesity, sedentary lifestyles, quantitative and qualitative changes in diets and the growing aging population.³ Recently the CDC listed diabetes as one of the medical conditions that may augment an individual’s risk of severe illness from COVID-19. Additionally, a study published in a recent issue of the Journal of the American Heart Association revealed that an estimated two out of every three hospitalizations due to COVID-19 were attributed to four preexisting conditions including diabetes, obesity, hypertension and heart failure.⁴

Despite having a better understanding about the pathogenesis of diabetes and the expanding treatment landscape of novel classes of drugs, rates of diabetes continue to climb and unfortunately many patients fail to meet glycemic targets. Researchers from the John Hopkins Bloomberg School of Public Health sampled data from the National Health and Nutrition Examination Survey (NHANES) to analyze trends in diabetes treatment and risk-factor control between 1999 and 2018. The sample included 6653 participants who were at least 20 years old, were not pregnant, and were diagnosed with diabetes by a physician.

Their findings were recently published in the New England Journal of Medicine and  researchers revealed that percentage of individuals achieving glycemic control, defined as HbA1c levels below 7.0%, rose from 44.0% between 1999–2002 to 57.4% between 2007–2010; however, that number then dropped to 50.5% from 2015 to 2018.^5,6 Researchers also noted that likewise, the percentage of individuals attaining blood pressure control (<140/90 mmHg) increased steadily from 64.0 % in 1999-2002 to 74.2 % in 2011-2014, then fell to 70.4 % in 2015-2018.^5,6 The results also indicated that the percentage of individuals with diabetes with control of hyperlipidemia, defined as non-HDL cholesterol lower than 130 mg/dl, rose dramatically from 25.3% in 1999–2002 to 52.3% in 2007–2010, but then stalled, reaching only 55.7% from 2015 to 2018. Moreover, the percentage achieving control of all three risk factors increased from 9.0% in the time frame of 1999–2002 to 24.9% during 2007–2010, thereafter falling to 22.2% between 2015 and 2018. ^5,6 

In a press release, one of the authors, Michael Fang, PhD, a postdoctoral fellow at the Bloomberg School and lead author of the study stated, “These trends are a wake-up call, since they mean that millions of Americans with diabetes are at higher risk for major complications. Our study suggests that worsening control of diabetes may already be having a detrimental effect at the national level.”⁶ 

Additionally, the study’s senior author Elizabeth Selvin, PhD, MPH, a professor in the Bloomberg School’s Department of Epidemiology stated, “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.” ⁵  

Dr Selvin also indicated that the two large clinical trials published in 2008 known as the ACCORD and ADVANCE trials may explain part of the new trend. These trials revealed that intensive lowering of HbA1c to very low levels did not demonstrate the cardiovascular benefits individuals had hoped. Some trial participants who had blood sugar controlled to very low levels had heightened risks of low-blood-sugar or hypoglycemia, which can be very serious. 

“As a result of these trials, what we may be seeing is that doctors of people with diabetes may have backed off a bit on glycemic control, with potentially damaging results,” explained Dr Selvin. 

Finally in the press release, Dr Selvin mentions that since the aforementioned trials, many new and improved diabetes drugs have become available and if HbA1c can be reduced with safer drugs that don’t cause hypoglycemia, then that will likely benefit the majority of patients. Dr Selvin also added that blood pressure control has dropped nationwide among the general population, and the blood pressure results in adults with diabetes in this study appear to follow that broader trend.⁶

Diabetes continues to be a major public health issue and the increasing rates of diabetes are alarming. The results from this study illustrate the challenges of controlling blood glucose and the urgent need to expand awareness about the condition itself, the health related complications associated with undiagnosed and uncontrolled T2DM and the critical roles of early diagnosis and clinical intervention. Some of the most essential facets of effective diabetes management is ongoing patient education, patient compliance to therapy, routine clinical monitoring, helping patients set realistic goals and reinforcement of target goals. 

As frontline health care providers, pharmacists are well poised to educate patients about diabetes in various clinical settings. Through patient education, pharmacists can expand awareness about the vital nature of adhering to therapy and nutritional plans to diminish the risks associated with uncontrolled T2DM and the incidence of major cardiac events. During counseling, patients should be reminded that they have an integral role in their own diabetic care and the overall management of their diabetes. Pharmacists can also use their drug expertise to make clinical recommendations tailored to patient need. Patients should be reminded that preventing and controlling diabetes requires commitment and a collaborative effort between patients and their caregivers. 

Finally, pharmacists can encourage and help patients set realistic goals, direct them to the numerous diabetes education/support resources including cost savings programs that are available through the various manufacturers. Pharmacists can empower patients with relevant clinical information that will enable them to make informed decisions about their overall health and hopefully inspire them to take control of diabetes. 

Disclaimer: The views and opinions expressed are those of the author(s) and do not necessarily reflect the official policy or position of the Population Health Learning Network or HMP Global, their employees, and affiliates. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, association, organization, company, individual, or anyone or anything.

References:

1. CDC. National Diabetes Statistics Report 2020. Centers for Disease Prevention and Control website. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf   
2. Diabetes Facts and Figures. International Diabetes Federation website. https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html.  Updated December 2, 2020. Accessed June 24, 2021.
3. Shaikh J. Why is diabetes increasing  in the United States? Medicine Net.com. https://www.medicinenet.com/why_is_diabetes_increasing_in_the_united_stat/article.htm. Published April 9, 2021. Accessed  June 24, 2021.
4. O'Hearn M, Liu J, Cudhea F, Micha R, Mozaffarian D. Coronavirus Disease 2019 Hospitalizations Attributable to Cardiometabolic Conditions in the United States: A Comparative Risk Assessment Analysis [published correction appears in J Am Heart Assoc. 2021 Apr 6;10(7):e020858]. J Am Heart Assoc. 2021;10(5):e019259. doi:10.1161/JAHA.120.019259
5. Fang M, Wang D, Coresh J, Selvin E. Trends in Diabetes Treatment and Control in U.S. Adults, 1999-2018. N Engl J Med. 2021;384(23):2219-2228. doi:10.1056/NEJMsa2032271
6. Major Study of Diabetes Trends Shows Americans’ Blood Sugar Control is Getting Worse.  Johns Hopkins Bloomberg School of Public Health website. https://www.jhsph.edu/news/news-releases/2021/major-study-of-diabetes-trends-shows-americans-blood-sugar-control-is-getting-worse.html. Published June 9, 2021. Accessed June 24, 2021.