Friday, October 18, 2019

Retrospective #244: Diabetes on Rise but Complications Decline

“Diabetes on the Rise but Complications Decline” was the title of a video on my Medscape Alert a while back. The subtitle was “Diabetes on Rise as Waistlines Expand.” Sounds to me like it’s another epidemiological analysis.
Declining complications and expanding waistlines are “sentinel indicators of outcomes,” in Type2 diabetes, according to the narrator. The data were collected from several very large public databases which “…examined 5 complications of diabetes – acute myocardial infarction [heart attack], stroke, lower extremity amputation, end-stage renal disease, and death from diabetic ketoacidosis…” The story references an article from the New England Journal of Medicine.
“We are all aware that we have epidemics of diabetes and obesity in the United States,” the narrator observed, but he didn’t attempt to explain why. The NEJM ABSTRACT made a similar observation, and added that “preventive care for adults with diabetes has improved substantially in recent decades.” It concluded that “rates of diabetes related complications have declined substantially in the past two decades.” Translation: Treatment of the blood glucose symptoms of Type 2 diabetes have reduced morbidity and mortality from the disease, but not addressed the cause.
The specific findings: “The diagnosis of diabetes increased from about 6.5 million in 1990 to almost 21 million in 2010, but the rates of major complications actually fell in all 4 age groups.” There was a 69% reduction in MI cases, a 53% reduction in strokes, “but the rates of MI and strokes were about the same.” There were also fewer cases of amputations (“a reduction of more than 50%”) and fewer cases of end stage kidney disease (“a reduction of about 28%”), and hypoglycemic (sic) crises declined by 65%. (NEJM article reported on hyperglycemic crises.)
The Medscape author opined, “It is hard to pick any particular factor,” he sais, but noted that “studies have shown that risk factor control, how you organized your healthcare system, and patient support for issues such as smoking cessation are all important in improving care, but certainly new drugs (e.g. statins) and such cardiovascular procedures as revascularization might help as well.” [Did he really call statins “new drugs”? He must be living under a rock.]
The video concluded, “The idea of using team-based care is promoted and probably an important factor; then repeats, “Medications are better, especially for lowering cholesterol, as are treatment of risk factors and patient education.
What the good doctors failed to mention in either the ABSTRACT or the Medscape piece is that the increased patients with diabetes is in large part due to the changes made in the diagnostic criteria for Type 2 diabetes.  In 1997 the threshold for diagnosing Type 2 diabetes changed from a fasting glucose level of 140mg/dl to 126mg/dl. Then, in 2002, the American Diabetes Association defined, for the first time, Prediabetes, enlarging the patient population. Prediabetes is described as impaired fasting glucose (IFG,) defined as a fasting blood glucose of 100-125 mg/dl. People with Prediabetes are at increased risk for developing Type 2 diabetes and for heart disease and stroke.
So, if you want to define changing standards for defining a threshold diagnosis of Type 2 diabetes and Prediabetes as “preventive care for adults with diabetes has improved substantially,” so be it. But changing standards for screening for and treating Type 2 diabetes are reasons why the ratio of complications (numerator) to number of cases diagnosed (denominator) is improving. As the denominator gets larger, the fraction gets smaller. That’s 5th grade math.
My beef with this report is that is both detached and delusional. If I were an MD clinician or PHD epidemiologist, I would take no comfort from this report. It is both detached and delusional in the sense that it’s like the deckhands rearranging the chairs on the Titanic as the ship sinks. Treating the symptoms of Type 2 diabetes is all these deckhands are doing. And deliberately creating misleading relative rather than absolute ratios is just a feel-good delusion.
In addition, the report doesn’t recognize that obesity itself is but a symptom of Type 2 diabetes, or rather of the larger Metabolic Syndrome, the mechanism of which is Insulin Resistance (IR). IR is the cause of the disregulated glucose metabolism and broken fat metabolism, that is the “sentinel indicator” of Type 2 diabetes that needs to be addressed.
But epidemiologists keep rearranging the deck chairs and clinicians keep writing scripts. It’s very sad. Tragic, really.

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