GUJHS. 2014 May; Vol. 8, No. 1: 17-27.
Abstract Type II Diabetes Mellitus (T2D) is one of the most prevalent chronic diseases in the United States healthcare system. Many of the known risk factors, such as obesity, hypertension, a family history of diabetes, a prior history of gestational diabetes, high cholesterol levels, or physical inactivity, have implications on the healthcare system and could in many cases have been prevented through a change in the delivery of care (CDC, 2013). Managing T2D brings up one of the major issues that inherently plague the United States healthcare system, which is addressing acute, episodic care, instead of practicing comprehensive and preventative care. The current system of payment does not address the root causes of T2D, which perpetuates the development of diabetes, significantly increasing the health expenditures in the U.S. healthcare system as it continues to pay for the management of T2D. A key player moving forward in the management of T2D would be the Accountable CareOrganizations (ACOs), who primarily focus on comprehensively maintaining the health of the patient. Care coordination and education between providers and patients, as well as an overall restructuring of care delivery in the healthcare system, may improve the health status of the population and reduce health expenditures in the long run. Keywords: Chronic disease, Type II Diabetes Mellitus, Accountable Care Organizations, Social determinants, Care management
Introduction of Chronic Diseases
Insulin-resistant diabetes mellitus, commonly referred to as T2D, is the most common form of diabetes, affecting 95% of people with diabetes (American Diabetes Association, 2014). In T2D, the fat, liver, and muscles of the body are unable to properly respond to insulin, which allows high levels of sugar to build up in the blood, resulting in hyperglycemia (NIH, 2013). Early symptoms of T2D are fatigue, hunger, increased thirst, increased urination, and bladder, kidney, skin, or other infections that are more frequent or take longer to heal (NIH, 2013). There is currently no cure for T2D. However, treatments include blood sugar monitoring, healthy eating, regular exercise, and some forms of diabetes medication or insulin therapy (Mayo Clinic, 2013).
There are many risk factors associated with T2D, some of which include: obesity, hypertension, a family history of diabetes, a prior history of gestational diabetes, high cholesterol levels, or physical inactivity (CDC, 2013). These risk factors are more commonly found in older populations as one’s health status continues to decline with age, leading to a higher rate of risk factors of T2D. Figure 1A demonstrates the positive correlation between T2D incidence and age, demonstrating that older age categories had higher rates of incidence of T2D. Due to the current declining health of the population of a whole in the United States, including higher rates of obesity and related co-morbidities, general incidence of T2D has also increased (Fig 1B). The risk factors mentioned above, such as being overweight or obese, having high blood pressure, and abnormal cholesterol levels are three factors that are most prevalent in African American, American Indian, Asian American, Pacific Islander, andHispanic American/Latino communities. Thus, many diagnosed with T2D in the United States fall into the aforementioned ethnic communities, which highlights the possible issue of health disparities. Figure 1C demonstrates the higher rate of diagnosed diabetes in groups of African Americans and Asians than in groups of Caucasians. Moreover, studies have shown that minorities for the most part have high complication rates when it comes to T2D, indicating possible discrepancies in treatment and management (Fig 3). Furthermore, the rate of diabetic end stage renal disease (ESRD) is 2.6 times higher among African Americans than Caucasians, which may be attributed to the interaction between hypertension and T2D (AHRQ, 2013).
Figure 1: Statistics of Noninstitutionalized Population with Diagnosed Diabetes, United States, 1980-2011. A. Percentage of civilians affected by age: increased incidence of diagnosis of T2D over a 30 year span in all age groups, with a significant increase in the 65-74 and 75+ age groups. B. Number (in millions) of civilians affected by age: increased incidence and steadily increasing prevalence of T2D in the United States population over a 30 year span, possibly demonstrating changes in the health of the population. C. Age-specific percentage of civilians by age, race and sex: higher prevalence of T2D among African Americans and Asian Americans in comparison to Caucasian Americans and increased prevalence of T2D with increased age for all represented groups. D. Age-adjusted percentage of civilians affected by education: those who did not graduate high school consistently had a higher incidence of T2D between 1980 and 2011 while those who finished high school or completed education ata higher level than high school maintained a similar incidence between 1980 and 1988; but those who had only completed high school had a higher incidence of T2D starting in 1988 (CDC, 2013).
The Challenges of Managing Type II Diabetes in the Current Environment There are many challenges associated with managing T2D because of the difficulty in addressing the root issues. Changing the root problems would revolve around a lifestyle change of factors that are often beyond the scope of control of the person affected by diabetes. The risk factors associated with T2D are highly associated with the social determinants of health, which can be defined as the circumstances in which people are born, grow up, live, work, and age, and the systems put in place to deal with illness, which are in turn shaped by a wider set of forces: economics, social policies, and politics (Social determinants, 2013). Being unable to afford or have access to healthy foods, which help to prevent obesity, hypertension, and high cholesterol, may affect the intake of proper nutrients and increase the intake of unhealthy foods. Additionally, safety and community issues may play a role in the amount ofphysical activity one can get. Health disparities influenced by these social determinants perpetuate risky health behaviors that can increase the chances of developing T2D. The differences in prevalence between different levels of education have increased between 1980 and 2011 (Fig 1D). This may be due to the same socioeconomic factors that affect various ethnic/racial groups that contribute to risky health behaviors. This, again, could possibly be linked to health disparities and the impact of the social determinants of health. Social determinants are difficult to overcome, especially if one is in a socioeconomic position in which he or she cannot address certain recommendations for lifestyle changes. This leads to poor health behaviors that lead to negative health outcomes later in life, such as T2D. Poor health behaviors, such as unhealthy diet and lack of exercise, are perpetuated throughout the lives of the individuals and by individuals in the community, which may lead toobesity, hypertension, and high cholesterol levels, all of which can lead to T2D. Once an individual is diagnosed with T2D, it is just as difficult to manage because the same social determinants that helped perpetuate the development of T2D are in place. The individual may still not have access to healthy foods, may still not be able to pursue an increase in physical activity, and may still not be able to take control of their own health. Managing T2D brings up one of the major issues that inherently plague the United States healthcare system, which is addressing acute, episodic care, instead of practicing comprehensive and preventative care. Currently, the reimbursement system pays more for procedures and acute episodes of care, such as heart attack and stroke, the rates of which are increased by the same risk factors that lead to T2D. Instead of receiving consistent, preventative treatment, people continue to practice bad health behaviors until they develop T2D. Although treatmentfor diagnosed T2D can be covered by insurance, actions taken to prevent T2D are not covered or addressed by the system. The current system of payment does not address the root causes of diabetes, which tend to be the social determinants of health. This perpetuates the development of diabetes, significantly increasing the health expenditures in the U.S. healthcare system as it continues to pay for the management of T2D. Currently, the Affordable Care Act (ACA) is expanding coverage through the health insurance exchange and Medicaid expansion. While this will be beneficial to those who previously could not afford insurance, this still does not address the problems associated with T2D, but is simply enabling more people to receive care for T2D. Although this is beneficial for the population, it does little to reverse the current pattern, and simply perpetuates the increase in prevalence. Another issue that makes T2D difficult to manage is the actual clinical management. It requiresconstant monitoring of blood sugar levels, as well as consistent adherence to prescribed medication. The National Diabetes Education Program has developed a four-step approach to managing T2D: Learn about diabetes, know your diabetes ABCs, learn how to live with diabetes, and get routine care to stay healthy (4 Steps, 2012). It is often up to the patient to seek out information to fully understand diabetes. Although the physician may explain diabetes, they can feel rushed and may not be able to fully explain management of T2D in a way that the patient understands due to health literacy barriers or language barriers (Marvel, 1999). While the Internet may be filled with information to adequately address diabetes concerns, many people are not able to access the correct information to learn about their diabetes. This brings up issues in the delivery of care and reimbursement system as well. Because reimbursements are higher for more complicated, acute procedures, physicians get reimbursedvery little to explain diabetes management to a patient (Green, 2013). Additionally, the hospitals make more money over time by treating diabetes, whether through the actual management, or through critical acute issues that may arise from the same risk factors of T2D, such as heart attacks and strokes. Overall, the current healthcare reimbursement system simply makes not preventing diabetes and not educating about diabetes more economically favorable (Green, 2013). The National Diabetes Program asserts that the patient must know their “Diabetes ABCs,” which are different health indicators that must be managed to lower the chances of having heart attacks, strokes, or other diabetes-related problems. “A” stands for the A1C test, which measures the average blood level over the past three months. If the blood level is too elevated, the heart, blood vessels, kidneys, and feet could be negatively affected. “B” stands for blood pressure, which must be measured to prevent the heart fromoverworking, which could result in heart attack or stroke. “C” stands for cholesterol. Low density lipoprotein (LDL) cholesterol buildup can result in heart attack or stroke, whereas HDL helps remove LDL cholesterol from blood vessels. Although the three ABC tests can monitor the chance of heart attack and stroke, studies have shown that there is still discrepancy in the delivery of these tests. The National Health Disparities report demonstrated that there were disparities between different races/ethnicities that had their hemoglobin (Hb) A1c levels, their total cholesterol, and blood pressure under control. (2010 National, 2010). The Agency for Healthcare Research and Quality (AHRQ) found a low rate of adults age 40 and over with diagnosed diabetes who had reported receiving the four recommended services. The highest percentage that received all four recommended services was the 60 and up age range at 30% (Fig 2). The four recommended services for diabetes include two or more HbA1ctests, a foot exam, a dilated eye exam, and a flu shot (AHRQ, 2012). Learning to live with diabetes and getting into a routine is highly influenced by the social determinants of health, especially in regards to economic resources. While the actual medications and tests may be paid for by insurance, the lifestyle change required for a diabetic may still be out of financial reach. Keeping track of blood sugar and checking blood pressure may also be difficult for many patients and many might not adhere to the medical recommendations. The National Diabetes Education Program also suggests seeing a healthcare provider at least twice a year for a blood pressure, foot, and weight exam, in addition to an A1C Test. It is recommended that once a year patients have a cholesterol test, a triglyceride test, a complete foot exam, a dental exam, a dilated eye exam, a flu shot, and a urine test (NDEP, 2013). It is clear from the study above that not all people with diabetes are receiving this processof care. The current healthcare system lacks a consistent primary care provider gatekeeper who would help facilitate to make sure these tests were performed in order to maintain the health of the patient. The lack of primary care provider (PCP) also brings up an issue in diagnoses. As mentioned above, it is estimated that approximately 7.0 million people do not know that they have diabetes (National Diabetes, 2011). Without consistent check-ups with a PCP, it is very difficult to determine whether or not one is suffering from diabetes, since the symptoms are not extremely obvious and become more evident over time. The Institute of Healthcare Improvement (IHI) has introduced the triple aim of healthcare would require developing three dimensions: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare (IHI, 2013). Currently, the healthcare system is not achieving these aims for diabetes. Overall, the main issues indealing with T2D are that the current delivery system is not focused on coordinated care or preventative care, the current reimbursement system is not focused on patient-centeredness, and the root causes of T2D are difficult to address. Figure 2: Adults age 40 and over with diagnosed diabetes who reported receiving four recommended services for diabetes in the calendar year (2+ hemoglobin A1c tests, foot exam, dilated eye exam, and flu shot), by age and residence location, 2008-2009 (AHRQ, 2012).
Best Practices for Management of Type II Diabetes
In order to facilitate optimal outcomes in diabetes management, several guidelines have been established outlining best practices. These best practices, once fully explored, can eventually be implemented as a standard process of managing chronic disease in an effort to increase the standardized, evidence-based practice that can lead to better health outcomes overall. The following are best practices in the clinical aspect of T2D care and the standards of self-management of diabetes.
The American Diabetes Association has created a framework of clinical T2D management. The first aspect of clinical care is classifying the types of diabetes and standardizing the measures of diabetes diagnosis and pre-diabetes diagnosis. In 2009, the International Expert Committee recommended the use of the A1C test to diagnose diabetes, with the threshold at greater than 6.5% (National Diabetes, 2011). This would also be used to determine the individuals who are between a healthy glucose level percentage and 6.5%, who would be defined as having impaired glucose intolerance. The next aspect of diabetes management would be testing for diabetes in asymptomatic patients. As previously mentioned, a lack of testing in a preventative capacity of testing to treat in the early stages can be hindered by a lack of PCP usage. Best practices suggest testing the A1C levels of adults of any age who are overweight, obese, or have other risk factors for diabetes, and repeating the tests every threeyears. The same A1C test that is used for diagnosis should be used for screening. Due to the long presymptomatic phase of T2D, as well as the increasing prevalence among populations, screening is recommended for adults with the risk factors of diabetes and children and adolescents who are overweight so that efforts can be taken to delay and prevent the formation of T2D. Best practices in preventing and delaying diabetes include losing 7% of body weight, increasing physical activity, and annual monitoring (National Diabetes, 2011).
Diabetes care must first begin with the initial evaluation of the type of diabetes as well as the risk factors that could lead to complications. A comprehensive, patient-centered plan must be established for the individual patient based on their medical condition to facilitate the disease management. This management would be assisted by a variety of health providers who would ideally work with this individualized plan. The next aspect of diabetes management would be glycemic control, which would require the assessment of glycemic control through regular glucose monitoring, and A1C tests that are administered consistently over the individually recommended intervals. Lowering the A1C below 7% has been shown to reduce complications associated with diabetes. However, the healthcare provider may recommend different levels for different patients. Metformin is the recommended pharmacological agent for T2D, while insulin therapy is usually used. Individualized medical nutrition therapy (MNT)should also be developed, with the mix of carbohydrate, protein, and fat contents adjusted to meet the metabolic goals and individual needs of the patient.
could potentially be a significant decrease in incidence of T2D, as more established processes of prevention and management are developed. This could lead to better outcomes of the United States population overall, by not only reducing the prevalence of T2D and its associated health risks, such as heart attack and stroke, but also by reducing risk factors associated with T2D, such as hypertension, obesity, and high cholesterol levels. This can lead to both a healthier nation and a decrease in health expenditures in the future. References 2012 National Healthcare Quality Report. (2013, May). Retrieved from
Age-specific percentage of civilian, noninstitutionalized population with diagnosed diabetes, by age, race and sex, United States, 2011. (2013, April 12). Retrieved from
Blue Cross looks to boost customers’ health affordably with new Quality Blue program. (2013, June 5). Retrieved from
Chronic diseases. (2009, December 17). Retrieved from
Diabetes disparities among racial and ethnic minorities. (2001, November). Retrieved from
Diabetes myths – American Diabetes Association. (2013, July 9). Retrieved from
4 steps to manage your diabetes for life. (2013, June 1). Retrieved from
Green, L., Savin, S., & Lu, Y. (2013, January). Primary care physician shortages could be eliminated through use of teams, nonphysicians and electronic communication. Retrieved from
Groups especially affected by diabetes. (2013, September 25). Retrieved from
Haas, L., Maryniuk, M., Beck, J., Cox, C. E., Duker, P., Edwards, L., …, Youssef, G. (2013). National standards for diabetes self-management education and support. Diabetes Care, 37(Supplement_1), S144-S153. doi: 10.2337/dc14-S144
Harris, J. R., & Wallace, R. B. (2012). The Institute of Medicine’s new report on living well with chronic illness. Preventing Chronic Disease, 9. doi: 10.5888/pcd9.120126
The IHI Triple Aim. (2013). Retrieved from
IOM: The ‘big nine’ chronic conditions. (2012, February 1). Retrieved from
Key concepts. Retrieved from
Marvel, M. K. (1999). Soliciting the patient’s agenda: Have we improved? JAMA: The Journal of the American Medical Association, 281(3), 283-287. doi: 10.1001/jama.281.3.283
National Diabetes Information Clearinghouse (NDIC). (2011). Retrieved from
Nutrition recommendations and interventions for diabetes: A position statement of the American Diabetes Association. (2008). Diabetes Care,31(Supplement_1), S61-S78. doi: 10.2337/dc08-S061
Prevent diabetes. (2012, May 14). Retrieved from
Punke, H. (2014, January 10). Early ACOs, medical homes show outcomes, cost improvements: Study. Retrieved from
Report brief – Institute of Medicine. (2012, January 31). Retrieved from
Resources. Retrieved from
Squires, D. (2012). Explaining high health care spending in the United States: An international comparison of supply, utilization, prices, and quality. Common Wealth Fund, 10(1595). Retrieved from
Tarver, T. (2013). Living well with chronic illness: A call for public health action. Journal of Consumer Health On the Internet, 17(1), 112-113. doi: 10.1080/15398285.2013.756758
Type 1 diabetes – American Diabetes Association. (2014). Retrieved from
