Diabetes: Past, Present, and Future

Highlights from the President’s Address
Alan D. Cherrington, PhD

Reported by Kimberly McFarland, PhD

Consistent with the title of his address, Dr Cherrington began by describing the environment for diabetes care and research in 1985. National healthcare costs for diabetes care were around $14 billion. The National Institutes of Health (NIH) spent $189 million on diabetes research. There were 5 insulin preparations, and recombinant human insulin was newly approved. The only oral treatments for type 2 diabetes were sulfonylureas. The infusion pump was in its infancy, and pancreas transplants had limited success.

Moving to the present, the number of patients with diabetes and the costs for diabetes healthcare have increased. There are now 13.8 million diagnosed and 5 million undiagnosed diabetes patients in the US. Forty-one million individuals are in a prediabetic state, and there are 1.3 million new cases of diabetes per year. In 2002, the US national cost for diabetes care was $132 billion dollars, and combined private and NIH contributions to diabetes research totaled $1 billion. The increases in diabetes can be attributed, in part, to an aging population and relative increases in minority populations with greater diabetes prevalence and poor levels of healthcare. Greater diabetes awareness and a change in diagnostic criteria may have also contributed. But the increase in obesity has certainly had a very substantial impact.

Diabetes care and research have advanced in the last 20 years. Clinical trial results demonstrated that tighter glucose control decreases the occurrence of complications. Currently available insulins allow better simulation of endogenous insulin secretion. Many new agents are available for the treatment of type 2 diabetes. Pumps and monitors are now smaller, more reliable, and more sophisticated. The success rate of pancreas transplantation has improved such that 60-70% of patients at the best treatment centers remain insulin-independent for 5 years. The Edmonton protocol, in which islet cells are injected into the portal vein, has made islet cell transplantation a reality. And non-physician healthcare providers play a significant role in patient care and education. However, although evidence suggests that diabetes can be prevented in at-risk populations, there is still no cure and no effective prevention strategy. And there is also room to improve healthcare quality. Because the majority of diabetes patients are seen by primary care physicians (PCPs), improving PCP adherence to care guidelines is important to improving healthcare quality.

In a sobering estimate of future prevalence and costs of diabetes (Wild S, et al. Diabetes Care. 2004), as many as 30 million people in the US will have diabetes, diagnosed or undiagnosed, by 2030. It is estimated that US healthcare costs will approach $250 billion that year. The remainder of Dr Cherrington’s address was devoted to the discussion of actions that should be taken to prepare for, and possibly prevent, this dire prediction. Dr Cherrington recommended the following 4 approaches.

Invest in research. Current research is focused on many promising diabetes treatments including insulins that are tissue selective, inhaled, or even orally administered; better representatives of existing drug classes; agents designed to inhibit pathogenetic mechanisms; and anti-obesity agents. In addition to pharmaceutical research, health system research is also needed to improve the cost-effectiveness and distribution of treatments. Given the eminent crisis in diabetes care, it is disturbing that government funding to NIH is decreasing. This will not only limit current research, but will also discourage students from pursuing research careers.

Develop a chronic care model for diabetes treatment. A chronic care model for diabetes treatment centers on productive patient-provider interactions. Implementing this type of model will require increased focus on training in patient-based approaches and incentives for good performance.

Promote early treatment and prevention. Unfortunately, the reimbursement process is still too complex to easily accommodate early treatment and prevention. Cost effectiveness will be an important concern in developing prevention and treatment strategies, as such strategies will likely require long-term implementation.

Combat obesity. Physicians need to encourage weight loss and exercise. Dr Cherrington also identified 3 additional actions to combat obesity: increase obesity research; encourage physical education and remove vending machines with unhealthy snacks from schools; increase exercise research.

Dr Cherrington ended his address with the following quote from Goethe.

“Willing is not enough, you must do.
Knowing is not enough, you must apply.”