Know Your ABCs of Diabetes... Please!

By Claresa Levetan, MD

Patients with diabetes are at increased risk for cardiovascular disease (CVD). In fact, CVD is the leading cause of morbidity and mortality in people with diabetes and is responsible for 75% of hospital admissions and more than 60% of deaths in this population.[1-4] Outcomes for people with diabetes and CVD are consistently worse than outcomes for people with CVD but no diabetes in all situations, including acute coronary syndromes, percutaneous interventions, and cardiac surgery. Overall, cardiac mortality rates for adults with diabetes are 2- to 4-fold higher than those for adults without diabetes.[1,5,6]

Because diabetes presents a significant threat to public health, 3 respected organizations—the American Diabetes Association (ADA), the American College of Cardiology (ACC), and the National Diabetes Education Program (NDEP) of the National Institutes of Health (NIH)—joined forces to promote a national program for prevention and intervention strategies. In 2001 the ABC program was targeted at both physician providers and patients to make them aware of appropriate diabetes care and treatment goals.

Aggressive management is emphasized in 3 key areas:

A1C levels should be <7%; blood pressure should measure <130/80 mm Hg; and LDL cholesterol should be <100 mg/dL, although the National Cholesterol Education Program's Adult Treatment Panel III recently recommended that an LDL of < 70 mg/dL is a reasonable therapeutic goal for people at very high risk for cardiovascular disease.[7] These goals are consistent with those of the ADA, the Joint National Commission on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure of the NIH, and the National Cholesterol Education Program (NCEP) of the NIH.[8-10]

Not all physicians are in the know

Recent research underscores the knowledge gap in diabetes basics among practicing primary care, internist, and generalist physicians. One recent national survey conducted among 200 practicing physicians who saw more than 460 diabetes patients per year demonstrated that physicians did not readily mention blood pressure and cholesterol as top items to check in their patients with diabetes. Only 23% of the physicians surveyed mentioned cholesterol, and 4% mentioned blood pressure as important checks. However, nearly all the physicians surveyed correctly named hemoglobin A1C as one of the most important tests for patients with diabetes.

Knowledge of current treatment goals was inconsistent as well. A majority of physicians did not correctly identify the ADA and American Heart Association targets for blood pressure and LDL cholesterol control.[11] For blood pressure treatment, 49.6% of the surveyed physicians gave the correct goal of <130/80 mm Hg. Older guidelines of 130/85 mm Hg were given by 16.8% of the physicians. This sample of 200 physicians yielded 35 different goals for blood pressure in patients with diabetes. Target LDL cholesterol goals varied—only 45% of the physicians surveyed identified the correct goal of 100 mg/dL, whereas 40% used the older 1997 ADA goal of 130 mg/dL. However, for patients with heart disease and diabetes, 72.6% of the respondents cited the correct treatment goal of 100 mg/dL.

Staying up-to-date

How do we account for the knowledge gaps among physicians and residents about the ABCs of diabetes care? Most likely, recent changes are to blame. The ADA added new cholesterol guidelines based upon recent studies, including the Heart Protection Study. The Joint National Commission on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure also updated its recommendations this year. Naming conventions can also be confusing. The name for glycated hemoglobin tests has been standardized to A1C by the ADA, the American College of Endocrinology, and the National Glycohemoglobin Standardization Group.

Chronic diseases like diabetes are difficult to control, and the field is changing so rapidly that new treatment goals and diagnostic criteria have not been well conveyed to physicians and internists in training. Clearly, the most serious complications associated with diabetes can be delayed or prevented. How to translate the new science of diabetes into practice in the US healthcare environment remains the greatest challenge.

References

1. National Institutes of Health. National diabetes statistics. Available at: http://www.niddk.nih.gov/health/diabetes/pubs/dmstats/dmstats.htm. Accessed December 3, 2002.
2. Centers for Disease Control and Prevention: The prevention and treatment of complications of diabetes mellitus: a guide for primary care practitioners. Atlanta, Georgia: Public Health Service, U.S. Department of Health and Human Services; 1991.
3. Centers for Disease Control and Prevention. Diabetes surveillance, 1993. Atlanta, Georgia: Public Health Service, U.S. Department of Health and Human Services; 1993.
4. Lewis GF. Diabetic dyslipidemia: a case for aggressive intervention in the absence of clinical trial and cost-effectiveness data. Can J Cardiol.1995;11:24-28C.
5. Stewart KJ. Exercise training and the cardiovascular consequences of type 2 diabetes and hypertension. JAMA. 2002;288:1622-1631.
6. Data Analyses of the STS National Cardiac Surgery Database (1993-1996). Available at: http://www.sts.org/doc/2986. Accessed May 2004.
7. Grundy SM, Cleeman JI, Merz NB, et al. for the Coordinating Committee of the National Cholesterol Education Program. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227-239.
8. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2005;28(suppl. 1):S4-S36.
9. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute, National Institutes of Health. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Available at:http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7card.htm. Accessed Dec 15, 2004.
10. National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report. Available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/. Accessed June, 2006.
11. Levetan CS, Sharma M, Magee MF. Do US physicians know the ABC’s of diabetes? [abstract]. Diabetes. Abstract Book, 62nd Scientific Sessions, Friday 14-Tuesday June 18, 2002:A26. Abstract 107-R.