The National Diabetes Education Program: Changing the Way Diabetes Is Treated

The past few years have been exciting for those of us who treat persons with diabetes. After decades of debate, the evidence that diabetes treatment can prevent or markedly reduce many of the long-term complications of the disease has now become overwhelming. Recent epidemiologic and prospective therapeutic trials examining this hypothesis have found that glycemic control will reduce the microvascular complications of diabetes in patients with either type of the disease (Table). The pivotal trial for patients with type 1 diabetes was the Diabetes Control and Complications Trial, a 10-year trial that was reported in 1993 and sponsored by the National Institutes of Health (1). This trial showed that for every 10% reduction in hemoglobin A1c, a corresponding 40% reduction occurred in the rate of retinopathy; similar reductions were also found in the rates of nephropathy and neuropathy. Table. Prospective Trials in Diabetes: Reduction in Complications Reduction of complications associated with tight metabolic control in patients with type 2 diabetes was demonstrated in a trial by Ohkubo and colleagues (2). This trial studied Japanese patients, who are less obese and less insulin-resistant than their western counterparts. The debate about whether the results of the Diabetes Control and Complications Trial (1) and the trial by Ohkubo and colleagues (2) applied to western patients with type 2 diabetes was settled by the reporting of the main results of the United Kingdom Prospective Diabetes Study (UKPDS) in September 1998 (4, 5). This long-term prospective trial of more than 5000 patients who had recently received a diagnosis of type 2 diabetes showed that a relatively small reduction in average hemoglobin A1c level (from 7.9% in the conventionally treated patients to 7.0% in the group receiving intensive care) resulted in significant reductions in microvascular complications (by about 25%) and overall diabetes-related events (by about 12%). In addition, the data suggested that no treatment method was associated with increased cardiovascular events. This latter finding is important because it directly contradicts the impression left by the University Group Diabetes Program in 1975 that the sulfonylurea tolbutamide was associated with increased cardiovascular events (6). The UKPDS did leave some doubt about the relative benefit of metformin compared with the sulfonylureas or insulin. The authors concluded that although there was room for further study, metformin may be advantageous in obese patients with type 2 diabetes (5). With regard to macrovascular disease, the data are not as clear. In the UKPDS studies, small reductions in rates of some macrovascular events were found after tighter control, but these effects did not reach statistical significance; neither study showed any deleterious impact of intensive treatment on macrovascular events. Combined with the results of the Diabetes Insulin-Glucose in Acute Myocardial Infarction (DIGAMI) study, which showed a survival advantage at 3 years in patients with acute myocardial infarction who received short-term, intensive insulin treatment, these data should motivate us to treat hyperglycemia more intensively in all patients with diabetes, with the goal of achieving an overall hemoglobin A1c level of 7% (7, 8). These emerging findings have prompted the National Institutes of Health and the Centers for Disease Control and Prevention to sponsor a major national initiative, the National Diabetes Education Program (NDEP). This program will develop strategies to improve diabetes care in the United States. The purpose of the NDEP is to improve the treatment and outcomes of persons with diabetes, promote early detection, and ultimately prevent the onset of the disease. The program has adopted four broad objectives: 1. To increase public awareness of the seriousness of diabetes, risk factors for diabetes, and potential strategies for preventing diabetes and its complications (target audience: the general public and persons at risk for diabetes). 2. To improve understanding about diabetes and its control and to promote better self-management behaviors among persons with diabetes (target audience: persons with diabetes and their families). 3. To improve health care providers' understanding of diabetes and its control and to promote an integrated approach to care (target audience: health care providers). 4. To promote policies and activities that improve access to and the quality of diabetes care (target audience: payers, purchasers, and policymakers). The NDEP is a multicomponent, integrated program that includes public awareness campaigns, special population strategies, community interventions, health system improvements, and a diverse partnership network. Diabetes quality-improvement activities fall under the health systems improvement component of the program. This program is modeled after successful national efforts to improve treatment of the two other major cardiovascular risk factors: hypertension and hyperlipidemia. During the past 2 years, the NDEP has sought advice on how best to approach diabetes treatment from more than 100 public and private agencies and organizations that represent the public, the health professions, and purchasers and payers of medical care. The major finding of a series of meetings was that diabetes was common, costly, and complex, yet controllable. An underlying theme was that the public, health care professionals, policymakers, and often patients themselves were not taking diabetes seriously. For example, in a survey conducted by the American Diabetes Association, only 8% of persons polled mentioned diabetes as a serious health problem. However, more than $90 billion is spent annually for direct and indirect services for diabetes and its complications; the prevalence of diabetes has increased by 12% in the past decade (9, 10). To address this problem, the NDEP and its partners have embarked on an aggressive strategy to improve the way diabetes is treated. In June 1998, a broad public awareness campaign was launched; it is now being expanded and includes messages tailored to members of the ethnic groups most affected by diabetes: Latin Americans, African Americans, Native Americans, and Asian-Pacific Islanders. This campaign urges persons who have or who are at risk for diabetes to know their blood glucose and hemoglobin A1c levels; the campaign also explains what these values mean. The NDEP has been working with professional groups to ensure that treatment guidelines and professional presentations are consistent. The American College of Physicians-American Society of Internal Medicine (ACP-ASIM) and other groupsincluding the American Academy of Family Practitioners, the Department of Veterans Affairs, the Health Care Financing Administration, the American Diabetes Association, and various organizations concerned with improving the quality of health carehave played an active role in this effort. Agreement on the definition of quality care for persons with diabetes is widespread, and we anticipate that each of the many organizations concerned will adopt similar care guidelines. Already, the Diabetes Quality Improvement Program and the Department of Veterans Affairs have each suggested various quality measures. In addition to improved knowledge about the value of treating hyperglycemia in type 2 diabetes, evidence is accumulating that treatment of the traditional risk factors of hypertension and hyperlipidemia is as beneficial (if not more so) for persons with diabetes as it is for those without the disease (11, 12, 13). In short, a comprehensive approach to improving hemoglobin A1c levels, blood pressure, and hyperlipidemia will most likely reduce the burden of diabetes and its complications as we approach the 21st century. Persons who would like to know more about the National Diabetes Education Program can visit the NDEP's Web site (NDEP.NIH.gov) or attend the NDEP workshop that will be held at the ACP-ASIM's annual meeting in New Orleans in April 1999. The time has clearly come for all concernedpatients, the public, physicians, and payersto take diabetes seriously.