Although the prevalence of diabetes has steadily increased in this country for years, recent acceleration of this trend has prompted widespread concern. Poor eating habits and inactive lifestyles contribute to the problem. Because individuals are developing diabetes earlier in life, they will have the disease longer and will require prolonged medical management for an increasingly complex constellation of symptoms. Along with the changing epidemiology of diabetes, there has been a shift in focus from microvascular to macrovascular complications. The impact of these changes, from the perspectives of health, functionality, and economics, makes diabetes a public health concern of staggering import. Standard approaches to the problem do not seem to be working. The diabetes epidemic continues, treatment effectiveness is limited, and costs seem to spiral. The following examination of pathophysiology, treatment considerations, and the managed care perspective will hopefully illuminate issues and initiate a discussion to challenge existing norms and reshape our approach to diabetes care.
Two primary defects contribute to the development of type 2 diabetes: insulin resistance and β-cell dysfunction. Elucidation of the interrelationship of these issues with the metabolic syndrome has led to improved understanding of the underlying pathophysiology, resulting in novel treatment approaches. As clinicians increasingly recognize that diabetes is not necessarily “all about the sugar,” the need for a different perspective on lifestyle management and pharmacotherapy emerges. New agents featuring distinct mechanisms and targeting a variety of defects have been introduced, which calls for an approach to drug selection that matches the strengths and limitations of particular drugs with specific patient characteristics. Managed care organizations may also need to rethink their approach to diabetes. Rather than focusing on drug costs, a broader view incorporating knowledge of the natural history of diabetes may be in order. Acknowledgement that aggressive, early management can alter the course of disease progression and prevent or minimize the impact of costly, debilitating complications can inform novel strategies. These could include value-based insurance design (Fendrick 2006) and a focus on wellness rather than disease.