Two weeks ago, the New York Times published an article penned by Elisabeth Rosenthal about Type 2 diabetes and its treatment. The article covered how Type 2 diabetics, seen as the new cash cow by the pharmaceutical industry, are being overwhelmed by costly drugs and tests. With the rising number of Type 2 diabetics, the cost of treatment is indeed a timely topic. But the article is also riddled with errors and misconceptions about Type 2 diabetes. More importantly, it places more emphasis on the cost rather than those suffering from the condition.
The article raised some good points about current Type 2 diabetes treatment. Although the article talks about the U.S., we who are outside the U.S. will recognize many of the issues raised. The good points of the article that I picked up are:
- There should be more support and financing (including from insurance companies) for diet changes and exercise as integral and principal parts of the treatment regimen.
- Doctors should not be pushing a concoction of expensive drugs as primary treatment for Type 2 diabetes.
- Diabetes drugs should not be expensive.
- Expensive drugs are not necessarily more effective than inexpensive (often generic) ones.
- Insulin should not be expensive.
- Insurance companies should not make access to treatment more difficult and expensive by requiring high co-pays and special approvals, and outright denial of credible alternatives.
The bad and the ugly
Part of the author’s answer to dealing with the rising cost of Type 2 diabetes was to trivialize the condition. She essentially put cost above the well-being of the patient. When I read that the author has a medical degree, I expected her to be more conscientious, discerning and careful in her research, statements and conclusions. At the very least, I expected her not to repeat errors and misconceptions about diabetes. Maybe I was asking too much.
Why compare Type 1 and Type 2 diabetes?
In trying to get her points across, Ms. Rosenthal thrashed Type 2 diabetes with her carefully selected but flawed comparison of the two main types of diabetes. For her, Type 1 diabetes is the “more dangerous cousin”, has more serious complications, and needs tight control and self testing, and Type 2 diabetes is the opposite. My initial reaction was to point out how equally dangerous Type 2 diabetes can be. But the difference between Type 1 and Type 2 is beside the point. There was no reason for Ms. Rosenthal to discuss certain features of Type 1 diabetes in an article that talks about the treatment of Type 2 diabetes, unless the author wants to steer the readers to the conclusion that Type 2 diabetics do not deserve the treatment that they need.
Speaking of Type 1 diabetes, Ms. Rosenthal describes Type 1 diabetes as the type “in which the body stops making insulin in childhood”. I thought that Type 1 diabetes affects people of all ages. Although a lot of people with Type 1 diabetes developed it when they were children or in their teens, the number of adults diagnosed with Type 1 diabetes, some even in their 60s, is certainly not negligible or mere exceptions. That’s why the name juvenile onset diabetes was discarded back in the ’90s.
Counseling cures Type 2 diabetes?
Ms. Rosenthal reported that a Ms. Neitling, a Type 2 diabetic, was “not diabetic anymore” after attending four nutrition classes and counseling. I read “not diabetic anymore” as saying that Ms. Neitling was cured. Wow. A cure. But where were the details? Ms. Rosenthal was writing about reducing treatment costs and yet did not give details and supporting evidence of “the cure”, which would certainly bring down costs. What nutritional advice was Ms. Neitling given? What type of counseling did she go through? Can she now drink ice tea sweetened with sugar together with scones and pecan pie and have the BGs of a non-diabetic? I want to know because I do not want to be diabetic anymore.
I am all for requiring diabetes education classes and counseling as part of a diabetic’s treatment and for insurance companies to shoulder the cost. And you will not get any argument from me about the importance of proper diet and regular exercise in controlling diabetes. In fact, a large number of Type 2 diabetics control their Type 2 diabetes with diet and exercise alone. But they are still diabetic – they still cannot eat carbohydrates the way their non-diabetic relatives and friends do and register normal post-meal blood glucose.
Type 2 diabetics do not have dreaded complications?
Ms. Rosenthal writes that, unlike our Type 1 cousins, we Type 2 diabetics “usually do not suffer some of the most dreaded complications” of diabetes such as blindness and renal failure. I want her to tell that to my fellow Type 2 diabetics who have renal failure, or whose visions are failing, or whose legs had to be amputated. It seems that we Type 2 diabetics “tend to die of heart attacks and strokes, and only after many years.” Is that supposed to make us feel better? Is that any comfort to those who have lost their Type 2 diabetic partners and parents to a heart attack, or to those who have to take care of Type 2 diabetics dealing with the effects of a stroke? And after many years of what? Suffering from speech impediments, loss of cognitive function or paralysis?
Ms. Rosenthal also failed to mention one crucial piece of information – that the risk of complications from diabetes increases, not simply because of type, but because of uncontrolled diabetes whatever the type.
SBGM – an unnecessary expense?
My biggest problem with the article is its dismissal of self blood glucose monitoring (SBGM) in Type 2 diabetes treatment. According to the article, self blood glucose monitoring is “too much intervention”, and that “there is no evidence that patients with Type 2 diabetes require daily home testing if they are not on insulin and are on stable doses of medicine” (citing unnamed doctors). While it mentioned that some doctors find that frequent testing may help some patients, in the same sentence it cited a study that intensive monitoring added stress. The article also made it appear that only pharmaceutical companies promote self testing to sell test strips and meters. But pharmaceutical companies are not the only ones promoting SBGM. Type 2 diabetics and advocates do as well. Advocates for Type 2 diabetes and proper treatment have been trying to refocus treatment protocol by putting BG control and self-testing on the forefront. SBGM is very much part of my diabetes control. I simply do not understand the disregard for SBGM.
I have a very simple question to the author and the so-called experts who frown upon SBGM.
How will I know how food, exercise, stress and medication affect my BG if I do not test?
Contrary to what Ms. Rosenthal and the experts may imagine, Type 2 diabetes does not come with ESP or any other psychic ability. While many of us can feel a hypo or perhaps extremely high BGs, we cannot tell a BG of 100 mg/dL from a BG of 200 mg/dL (that is, BGs that are not in the extreme high or extreme low). Diabetics who have lived on a very high carbohydrate diet experience “false hypos” when they reduce their intake of sugar and simple carbohydrates. How do they know that their BG is in fact 80 mg/dL, and not 50 mg/dL, unless they test?
Without testing, we cannot confirm which diet change, food advice, exercise or medication works for us. For example, experts say that we should eat whole grains such as brown rice. Let me tell you that my body cannot tell the difference between brown rice and white rice, and my BG will shoot up regardless of the color of the rice. I know because I test. The three most important words that a diabetic learns are – test, test, test. Type 2 diabetics also react differently to food, certain exercises and medication. So, yes, you may be able to tolerate the brown rice that I cannot tolerate, or I may be able to tolerate the apple that you cannot. For some, it may not be the food per se but the quantity. That’s why we say your mileage may vary. Treating Type 2 diabetes without self testing to me is like driving a car blindfolded.
Of course I understand that it’s a cost issue. But the critics of SBGM are cutting costs in the wrong places and promoting the wrong solutions. Diabetics, medical practitioners, diabetes educators and other support providers, regulators and even insurance companies should exert pressure on the pharmaceutical companies to lower the price of test strips and to make strips more reliable. We should join forces to find solutions to reduce cost while allowing diabetics to test as they need.
Here is one arrangement to consider. Standard diabetes treatment should include, at the very least, intensive testing for at least 3-6 months after diagnosis to enable the newly diagnosed Type 2 diabetic to learn how food, exercise, stress, and medication affect his BG. After that intensive testing period, the number of tests a day can be reduced and can be tailored to the diabetic’s needs as the doctor and the patient may agree on. I would also suggest that one month’s intensive testing per year will be very helpful in monitoring changes. I’m sure there are other suitable arrangements. But testing once a week, once a day, or none at all, are not acceptable options.
There was mention of how SBGM can be stressful for some people. I will grant you that. But the answer is not to cut down on all self testing but to help people deal with it. Based on my own and other diabetics’ experiences, many of us learn to adjust our testing, including reducing the frequency, based on our own personalities and proclivities.
The bottom line is that self-testing is not too much intervention. It is a necessary intervention.
As I wrote at the beginning of this post, the article raised timely and important issues on the treatment of Type 2 diabetes. But the author’s response was to make Type 2 diabetes seem insignificant. She expects us to manage our diabetes without the necessary tools.
The biggest hole in the article is the absence of the Type 2 diabetic community. Ms. Rosenthal focused on doctors and researchers, many unnamed ones, on the assumption that they are the “experts”. But she did not seek the experts on Type 2 diabetes, the diabetics themselves. Sure, she mentioned three Type 2 diabetics but only because their stories supported her conclusions. But where are the voices of the rest of us who know that Type 2 diabetes can be as dangerous as other types of diabetes, who value the importance of tight control and self-testing, and who educate ourselves about our condition so that we can make informed choices on our treatment (for example, whether we should take drugs and which one)?
We are not that difficult to find. We have taken advantage of the digital world. We are very much part of the diabetic online community. We have blogs and are active on Facebook, Twitter, and various online communities and forums. You just have to want to find us.
Do not just talk about us. Talk to us. We are here.