Diabetes Mellitus type 2 is one of the most deadly epidemics of the 21st century. Diabetes is the 7th highest leading cause of death1. Even those it does not kill, it severely compromises their lifestyle and health. The known macro vascular consequences of diabetes are CAD, PAD, and stroke. The microvascular consequences are retinopathy, neuropathy, and nephropathy2. With all these known comorbities and how deadly this preventable disease can be, it is astonishing that we are not doing a better job controlling the disease. It affects over 30 million people in the United States and over 180 million people worldwide3. The direction our country is heading is alarming with 84 million Americans diagnosed with prediabetes in 20153. Even these enormous numbers do not demonstrate how out of control this disease has become. Only 11 percent of people who have prediabetes are actually aware of their diagnosis4. There is also the economic burden to consider with Diabetes. In 2012 the estimated cost spent by the United States for diabetes was over 245 billion dollars5. Even with these known facts, the rate of diabetes continues to rise and the number of people with type 2 diabetes mellitus is estimated to double by the year 20306.
Part of the problem is lack of screening, even though the screening process itself is fast, affordable, and assessable for almost every facility and health clinic in the United States. The second problem, and possibly the main problem, is patient education and compliance. Sadly, 70% of those diagnosed with prediabetes will progress to type 2 diabetes over time4. Currently the term “prediabtes” refers to high fasting plasma glucose between 100-125 mg/dL or an A1C score between 5.7-6.4%7.
Our hypothesis is that saying “prediabetes" is misleading to many patients because it makes them believe they
do not have the disease yet, which is not the case. At the prediabetes stage, the body has already been compromised and is not processing glucose optimally and the disease will progress if not treated properly with diet, exercise, and even possible pharmacological intervention8. Lifestyle interventions are the most desirable treatment plan but unfortunately these forms of treatment are difficult for patients to maintain and over time the disease progresses8. Most patients would benefit from pharmacological intervention such as Metformin to enhance the action of insulin in liver and skeletal muscle which has been proven in large, well-designed, randomized trials9. Yet many patients will refuse medication because at this point they do not see the need for pharmacological intervention. We hypothesized that if different language was used when explaining their diagnosis that patients would be more willing to follow doctor recommendations and be more compliant with their treatment plan.
Materials and Methods:
At the Patient Care Center in Pomona, California, surveys were randomly distributed to patients within the building in January 2018. The Survey contained five questions about demographics and identification, followed by seven questions about perception of diabetes. The first five questions asked about gender, age, race, marital status, and highest level of education. The diabetic questions asked, “If you were told you had pre-diabetes and you are managing with diet/exercise, do you think you need to take medication?” The patient had the option of circling yes or no. This was followed by the exact same question but this time asked about “stage 1 diabetes” instead of “Prediabetes”. “Stage 1 diabetes” is not a real term but is the proposed test phrase that was supposed to be synonymous with prediabetes. The third question asked, “On a scale of 1-10, 1 being completely healthy and 10 being a severe condition, how serious do you think pre-diabates is?” There was a space for patients to circle a number 1-10. The next question was the same but for “stage 1 diabetes” instead. The fifth question asked what age healthy individuals should be screened for diabetes. The next questions asked what the patient had been diagnosed with in the past and if it changed their life style. The final question asked if they would be willing to start taking medication if they were told they had stage 1 diabetes.
Results:
44 surveys were completed with 39 percent male and 61 percent female. 34 percent were married, 43 percent were single, and the remaining 23 percent were either separated, divorced, or widowed. 39% were Hispanic, 27% white, 14% African American, 9% Asian, 9% multi-racial, and 2% Native American. 36% of the participants were previously diagnosed with diabetes, prediabetes, or insulin insensitivity. Of those, 69% said they had made some sort of lifestyle change after being diagnosed— 18% made diet changes, 9% implemented exercise, 27% started taking insulin, and 45% incorporated all three changes. However, of those previously diagnosed with “prediabetes” 33% did nothing after being diagnosed. Out of this same group of patients who had previously been diagnosed with prediabetes, none had started taking medications when diagnosed, but over 66% say they would be willing to start medications if they had been told they had “stage 1 diabetes”.
Only 39% of the respondents stated they thought someone with pre-diabetes should take medications, whereas 59% said they believed people should take medications if diagnosed with “stage 1 diabetes”. The average perceived severity of “prediabetes” was 6.36 out of 10, while the perceived severity of “stage 1 diabetes” was 7.43 out of 10. That is a 17 percent increase in perceived severity. 86% of participants stated they would be willing to take medications if they were told they had “stage 1 diabetes”. Compare this to the 61% who stated they do not think medication is necessary for someone with prediabetes. 11% of participants were unsure of when healthy individuals should be screened for diabetes and 34% said people should be screened before the age of 18.
Discussion:
The focus of our study was on how patient education could improve diabetes control. Our hypothesis was that patients do not respond to the term “prediabetes" as well as they might to other language such as our proposed term “stage 1 diabetes”. Our results confirm this hypothesis with patients being 20% more likely to think medications are necessary and 86% of the respondents being willing to take medication if diagnosed with stage 1 diabetes. It has already been shown by many other studies that lifestyle interventions are the most desirable treatment plan but unfortunately these forms of treatment are difficult for patients to maintain and over time the disease progresses9. Pharmacological interventions such as Metformin would benefit most prediabetic patients because multiple well designed, randomized studies have shown how Metformin can enhance the action of insulin in liver and skeletal muscle8. Our study results demonstrated that many patients will refuse medication when diagnosed with prediabetes because they do not see the need for pharmacological intervention. 0% of those diagnosed with prediabetes were taking medications, and yet out of that select group 66% would be willing to take medications if they were told they had stage 1 diabetes.
As stated earlier, the term “prediabtes” refers to high fasting plasma glucose between 100-125 mg/dL or an A1C score between 5.7-6.4%7. It is not “full blown diabetes” until you reach an A1C score of 6.5%. However, nothing magically changes when you go from an A1C score of 6.4 to 6.5. In fact, those at the prediabetic levels are already at elevated risk of damage to the microvasculature and macrovasculature, resembling the long-term complications of diabetes9. So why is it suddenly “full blown diabetes” and not diabetes at 6.4? Diabetes is a progression and should be staged accordingly.
Based on the results of this study we propose a new naming system to help improve patient compliance and overall outcomes for diabetes. An A1C score below 5.7 is considered to be healthy. An A1C between 5.7-6.5 would be classified as “stage 1 diabetes” and should likely be treated with Metformin and lifestyle changes. “Stage 2” is an A1C between 6.5-9.5 score. In stage 2 the first step would still be lifestyle changes and Metformin but the additional second step if they are not at goal after 3 months could be to add a second agent. If they are still not at goal when they come back again consider adding insulin. Stage 3 is an A1C above 9.5 and treatment could immediately start with insulin. Stage 4 could be uncontrolled diabetes above an A1C of 12 or diabetic emergencies.
Future Studies could include implementing these survey findings into more practical experiments. Such an experiment could have one group of physicians tell the patient that they have Pre-diabetes and the other group of physicians use the phrase Stage 1 Diabetes. From there, the study could follow the patients for a certain length of time to see what changes were made, how was patient compliance, and how the overall A1C score was effected.
Conclusion:
In conclusion we believe that the diabetes epidemic can become much better controlled if we focus on two main components of the problem: Screening and patient education. Patient education is of utmost importance because this is what will lead to higher patient compliance. Sometimes clinicians try their best to educate their patients but due to the language used the patient will not properly understand the severity of the problem even after an in depth explanation. A similar change of verbiage from “pre-diabetes” to “stage-1 Diabetes” could be a huge solution to the problem. Based on this initial survey, patient perception of the disease in terms of severity is 17% greater when using the term “stage-1 diabetes”. This will hopefully directly correlate with a much better patient compliance. As already shown from the results of the survey, 86% of patients would start taking medications or at least be willing to do so if they were told they had “stage-1 diabetes”. In contrast 61% of patients said they would not take medication if they had “pre-diabetes”. This is a stark contrast and an alarming finding if we want patients to be compliant with their treatments. Diabetes is a huge problem in the United States as well as around the world and yet many of the symptoms can be prevented and the progression can be slowed by patient compliance which stems from effective patient education. We believe that renaming “prediabetes" can be one of the changes to massively improve diabetes management.
Article by Trent Brookshire
References:
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