Results when you need them: Tight control’s immediate impact

Diabetics get short-term gains from tight glycemic control

Tight glycemic control can help diabetics feel better fast, according to a Harvard study that provides the third leg of a now-sturdy tripod of evidence showing control is not only the best way to go, it is really the only way to go.

Adding to the Diabetic Control and Complications Trials (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) results showing the benefits of tight control for long-term prevention of complications, the Harvard study shows even small improvements in blood glucose levels have immediate and palpable effects on quality of life and work productivity of mild-to-moderate Type II patients. (For more on the DCCT and UKPDS, see Diabetes Management, November 1998, pp. 77-80.)

This is likely to have sweeping effects on diabetes care and on the way managed care and employers look at the disease.

"This study now rounds it out," says Gerald Bernstein, MD, president of the American Diabetes Association and a practicing endocrinologist in New York City. "You need to direct patients to get their blood sugars normal, without hypoglycemia, because they will function better in all ways in society."

Where once patients with the disease known as the "silent killer" were told glycemic control would benefit them five, 10, or 15 years down the road, now they can see for themselves that even a small reduction in blood glucose will make them feel better in as little as 24 hours, says the study’s lead author, Marcia Testa, PhD, MPH, senior lecturer at Harvard’s School of Public Health in Boston.

"Even if you can reduce blood glucose levels and HbA1c a half a percentage point, you will probably get some improvement in quality of life and relief from fatigue," she says. "Everybody lives on a very narrow edge of what he has to do, and that little bit of fatigue can actually make it impossible to function the way he wants."

Helping patients live better lives

A better quality of life and healthier patients translates into fewer doctors’ office visits and hospitalizations, and for employers, an average reduction of $91 per month per employee in paid sick days, the study shows. Specifically, the study showed even with minor reductions in blood glucose levels, patients slept better and had better cognitive function and measurably better work productivity.

"These are not the life and death symptoms, but they are the ones that make us live from day to day," says Testa. "I think they are very important to people who, if they can function just a little bit better, would be very grateful and would almost do anything once they feel that good not to go back to the way they were feeling before."

The study showed patients were better controlled with the use of oral drug agents than their peers who struggled to keep blood glucose down with diet and exercise alone. And even a small improvement in quality of life may be just what patients need to bring them into compliance.

For example, Testa describes a typical patient, a middle-aged obese woman, newly diagnosed and with no real glycemic control. It’s a Catch-22, she says. "What’s the first thing you tell them? To diet and exercise, right?" Testa asks. "First of all, they don’t have the energy, so how are they going to start? Then the patients begin to feel blamed, and they have feelings of guilt.

"So actually, if you can give them a kick by bringing blood sugar down and checking thyroid because the disease goes hand in hand with hypothyroidism, their engines get going and all of a sudden, they are in a cycle with the ability to have diabetes self-management work."

In addition, say both Bernstein and Testa, attention given to commonly overlooked symptoms of diabetes such as fatigue, weakness, and memory lapses, can lead to early diagnosis and may even bring in from the cold some of the estimated 8 million undiagnosed diabetics in the United States. (See list, p. 91.)

Bernstein says, "The Harvard study is important because it speaks to what the immediate effects of an elevated blood sugar are. And there are many people who walk around with blood sugars of 200 or 300, and they are basically unaware of it because they have adapted to it.

"Now that we’re getting aware of the long-term effect and with our concerns about blindness and kidney failure, we know an elevated blood sugar is toxic material and it interferes with the function of everything in the body," he says.

Steven Edelman, MD, diabetologist at the University of California San Diego Medical Center and staff member at the VA Medical Center in San Diego says, "Diabetic care has not been changing because of lack of patients’ education, motivation, and involvement in their own care."

Now the Harvard study provides impetus to patients, he says. "There’s a huge emotional component to the disease that includes guilt and fear — a lot of fear. There’s no question people feel better in the short term, too. And when people are under control, there is a level of confidence that they are doing everything they can to prevent some of the complications of diabetes."

Edelman, a Type I diabetic who was diagnosed 28 years ago, thinks the short-term quality of life improvements will also provide an incentive for patients to tackle the admittedly tedious task of long-term disease management. "The biggest problem is being tethered to a schedule. It gets tiring to do everything right — eating and testing and exercising properly — day in and day out."

In addition, he says, "The study is a way to tell managed care companies, Don’t be short-sighted. It means long-term savings, even if your patient switches to another HMO seven years from now. You’ll still have cost savings.’"

Testa’s 15-week study conducted with Donald Simonson, MD, of Brigham and Women’s Hospital, Joslin Diabetes Center, and Harvard Medical School, all in Boston, involved 569 male and female volunteers with mild to moderate non-insulin-dependent diabetes. Patients were taken off all oral agents for three weeks and divided into two groups, one receiving glipizide gastrointestinal therapeutic system (Glucotrol XL) for 12 weeks and the other, a placebo.

Patients completed a confidential form containing more than 100 questions detailing their experiences in a variety of areas of physical health, psychological well-being, mental abilities, and sexual functioning. They also reported number of days missed from work and days where ill-health curtailed their normal activities. (See sample list of questions, p. 90.)

What kind of care do employers pay for?

As expected, patients on glipizide had significantly better blood glucose control (7.5% vs. 9.3% for the placebo group), but those on oral agents consistently reported better quality of life on all areas assessed in the questionnaire. Factoring in work loss and increased doctor’s office visits, the improvement resulted in concrete dollar savings. Testa found that the group on diet alone was nearly five times more likely to miss work because of illness.

Those numbers provide employers with a powerful tool when selecting managed care plans for their employees, Testa says. "The employer is paying for it when he has an employee who is tired and can’t think and doesn’t come to work," she says. "I don’t think employers do enough to evaluate plans."

She urges employers to ask what programs the companies have in terms of education and prevention, which can, and will, result in real savings.

"One of the reasons we focused on the economic side of it was to make the point that managed health care groups who are denying what I call diabetes specialist care could have detrimental effects," Testa says.

"[Managed care organizations] saying we only need one diabetologist per million people or that they won’t fund diabetes nurse educators or dietitians was a move in the wrong direction," she concludes.

For more information, contact: Marcia Testa, Harvard School of Public Health at (617) 432-2818.