When bigger isn’t necessarily better

When bigger isn’t necessarily better

Much is being made of a study published in the
December issue of Diabetes Care which states the
number of people in the United States with diabetes will nearly double over the
next 25 years, while spending on the disease will nearly triple.

According to the study,
commissioned by Novo Nordisk (NYSE:NVO), 44.1 million people will have diabetes
in 2034, while spending on the disease will total $336 billion. Those figures
are currently 23.7 million and $113 billion, respectively. Meanwhile, Medicare
patients with diabetes will more than double, from 6.5 million to 14.1 million,
while Medicare spending will go from $45 billion this year to $171 billion in

The fact that diabetes is
growing at epidemic rates and is morphing into a major healthcare and economic
issue is hardly news. The real question everyone should be asking is; do these
facts change anything? Just because diabetes is growing at epidemic rates will
that fact translate into better care for patients? Will this fact somehow
change the challenging market dynamics faced by glucose monitoring companies or
improve the prospects for new drugs? Will this news somehow, magically get
everyone to wake up and understand that educating patient is the key to
improving outcomes?

Diabetic Investor would like to
believe that the answer to these questions would be yes. Unfortunately we have
been around long enough to know that huge and growing patient population does
not necessarily translate into anything more than a good press release. The
reality is the real message companies such as Novo are sending here is “Novo is
well positioned to sell even more of the products we make and therefore will
make even more money.”

It would real news if someone
actually was doing something to help slow the epidemic growth rate or actually improve
patient outcomes. From the first day Diabetic Investor came into existence our
hope was that one day we would put out of business. As much as we enjoy what we
do, nothing would make us happier than finding a cure for diabetes. Realizing
that it is unlikely we’ll see such an event during our lifetime, a more
realistic hope is that one day patients will receive the education they so
desperately need. Education that will help them better manage their diabetes.

The fact is diabetes is extremely
complex disease and while hundreds of very talented people are working on
finding a cure, a cure remains nothing more than a pipe dream. While it’s
gratifying to see better, more effective drugs and devices coming to market,
these new drugs and devices won’t help much unless the patient understands why
and how to use them.

A prime example of this can be
found in the results of another study
published in the November issue of
Diabetes Care. In a study entitled “Factors Predictive of Use and of Benefit
From Continuous Glucose Monitoring in Type 1 Diabetes” the authors made the
following statements;

“Subjects in all age-groups who preformed >6
meter measurements/day were more likely to use CGM on a near-daily basis than
those who were monitoring fewer times a day. One possible explanation is that those subjects who were
monitoring their blood glucose frequently were using these multiple
measurements to self-manage their diabetes and as a result could more readily
incorporate information from CGM into their already intensive diabetes
(Highlighting added by Diabetic Investor)

Simply put these patients VALUE the
information provided by their glucose monitor and they USE this information for
their own PERSONAL benefit. While gathering this information is easier with a
CGM, they could actually care less how they gather the information; the
important thing is not how they got the information but that they VALUE the

“A higher percentage of CGM glucose values
in the range of 71 to 180 mg/dl during the 1st month (with fewer
vales > 180 mg/dl) were predictive of greater use in month 6 even after
adjustments for the amount of CGM use. This could reflect the fact that those who observed the
most benefit early in their usage of CGM were more likely to recognize the
advantages of sustained use of CGM. Conversely, individuals with more values
> 180 mg/dl may felt discouraged and therefore less inclined to use the
(Highlighting added by Diabetic Investor)

Translation; patients are humans and humans
like good news and are likely to avoid bad news. This is something that should
be obvious to everyone. The fact is, it is human nature for patients to
continue to perform a task that confirms their on the right track. This is like
a person who’s on a diet who continues to step on the scale. The simple fact is
patients like constant, positive reinforcement. On the other hand, patients
don’t like bad news and will do anything they can to avoid it.  You don’t see obese patient’s weighing
themselves with great frequency as it just one more reminder that they have
failed to control their weight.

It is this study, although not designed to reinforce the need for better
patient education, actually shows the value of education. As if we needed even
more evidence of the value of education take a look at another study also
published in this month issue of Diabetes Care entitled “Cost-Related Nonadherence to Medications Among Patients With Diabetes and
Chronic Pain”. The authors of the study set out to see if financial constraints
were a factor in patients not taking their medications. It is well known that
therapy non-compliance is a major reason why nearly two-thirds of all patients are
not achieving control. It’s seems logical that with the current poor economic
conditions that patients would cut back taking their medications to help save

The authors concluded;
who forgo medications for both diabetes and chronic pain appear to be
influenced primarily by economic pressures, whereas patients who cut back selectively on their
diabetes treatments are influenced by their mood and medication beliefs.
Our findings point toward more targeted strategies to assist diabetic patients
who experience CRN.”
(Highlighting added by Diabetic Investor) Simply
put while cost played a role in the patients decision not take their
medications regularly for patients with diabetes their decision to be
non-compliant was influenced by what they knew or should we say, didn’t know
about their medications.

The authors go on to state;” Rather, selective underuse of diabetes
medications due to “cost” was associated with depression and negative beliefs
about pharmacotherapy. Dissatisfaction
with information about medications
—but not depressive symptoms—increased
the likelihood that a patient would report selectively foregoing his or her
pain treatment.”
(Highlighting added by Diabetic Investor) Put another
way, if the patient understood what the medication did and all the various side
effects they would be more likely to take their medications. Or made even
simpler, if someone had bothered to educate the patient about their medication
they just might take it when their supposed to.

There are those who would argue that education is the responsibility of
the patient and the patient has ample resources to obtain this education. They
could ask their physician, educator or pharmacist. If none these people were
available they could easily suffer the internet. While Diabetic Investor agrees
with this position up to a point, like so many things, when you live in the
real world things don’t always work as planned. The facts are nearly 80% of
patients with diabetes are treated by a primary care physician who lacks the
time, infrastructure and is not compensated for providing patient education.

An educator would be an excellent choice; unfortunately the majorities of
patients either don’t work with or have access to an educator. According to the
American Association of Diabetes Educators (AADE), there are 15,000 Certified
Diabetes Educators. According to the American Diabetes Association (ADA) there
are over 26 million patients with diabetes. You do the math.

The pharmacist is another good option until you consider the burdens already
placed on the pharmacist. While they have the knowledge base, they don’t have
the time. 

The internet is an excellent option until you look at all the
misinformation available. Frankly anyone with an opinion can write a blog and
many do. Just by way of example type Byetta into Google and over 500,000 hits
come up and what shows up near the top of the page a reference to Byetta and kidney
problems. This is not to say there aren’t any helpful web sites and blogs available,
only that as valuable as the internet can be it does have its limitations.

In the real world education is really no different than treatment, as it often
takes a combination of people and technology to achieve better outcomes. The
reality is a better educated patient base would actually do more to increase
the sales of drugs and devices than the epidemic growth rate of the number of
patients with diabetes. Does it really matter if you have 26 or 50 million uneducated
patients? The results would be the same the only fact that would change is that
even more patients would not being taking their medications or using their
devices regularly.

So let’s not delude ourselves into thinking that somehow the epidemic
growth rate of diabetes will do anything more than create even bigger problems until
something is done to deal with the real problem which is a lack of even basic
patient education. The funny, or should say sad, thing is everyone – the patient
– our overburdened healthcare system – the many companies in the diabetes
sector – would benefit from a better educated patient base. This is the
ultimate win-win-win scenario.

Or as Derek Bok, a former president of Harvard University, once stated; “If
you think education is expensive, try ignorance.” When it comes to diabetes, this
continued ignorance carries with it not only financial consequences but needless
suffering by millions.