Most diabetes patients need drug therapy and coaching

About 25.8 million Americans-8.3% of the U.S. population-have diabetes. Of those, 7 million do not know they have it, and the risk for death among people with diabetes is double that of people without the disease.

Diet, exercise and weight loss are helpful in controlling blood glucose levels, but most patients ultimately require drug therapy. Used alone, oral medications generally lower hemoglobin A1C levels by 0.5 to 1.5%. Most patients with type 2 (adult onset) diabetes eventually require multi-drug therapy or insulin.

"When insulin is added to oral agents, it is usually given either in the evening or at bedtime," says Mark Abramowicz, MD, editor-in-chief of The Medical Letter on Drugs and Therapeutics, a non-profit newsletter that critically appraises drugs. "In a three-year comparison of different ways of using insulin, all regimens achieved similar A1C levels (6.8-7.1%), with the greatest weight gain and hypoglycemia in the group that took insulin before meals and the least in the group that took insulin at bedtime."

"Treating to this target has clearly been shown to prevent the microvascular complications of retinopathy and nephropathy," says Dr. Abramowicz, "However, whether it prevents macrovascular outcomes such as heart attack and stroke is unclear. Three large trials have found no decrease in these events, even with intensive glucose control. Levels near 7% may be prudent in older patients with a long duration of type 2 diabetes, and in those with underlying cardiovascular disease, frequent hypoglycemia or multiple diabetes-related complications."

HealthPartners, with about 1.4 million members in Minnesota and western Wisconsin, has developed a special program to serve high-risk members with diabetes.

"We frame this as an intrinsic approach," says Karen Kraemer, vice president of disease and case management. "We've actually done a great deal of training and development so our health coaches are able to have a conversation that elicits the helping abilities of the individual themselves."