As we explored in earlier posts, the United States faces a growing epidemic of obesity-related chronic conditions such as type 2 diabetes, hypertension, and cardiovascular disease. This tsunami of preventable sickness impacts 133 million people in the US, and these numbers will continue to rise without sweeping changes to our modern culture and lifestyle habits.
It is striking that national surveys have shown deterioration over the past 50 years in key health indicators for the US population, particularly obesity, blood glucose, blood pressure, and blood lipids (collectively referred to as metabolic syndrome). These red flags alert us to the fact that we must all do more to change not only our culture and lifestyle, but also the attitudes of the medical community and the way it presents treatment options if we are to help patients avoid serious and costly medical complications.
Most patients, when fully informed, probably want to avoid serious health complications and live healthy and productive lives. The primary goal of the US healthcare system, therefore, ought to be to help patients make more empowered decisions about their own health – in ways that fit their personal values and beliefs. In today’s healthcare system, many patients are left in the dark regarding their treatment options, as well as the benefits, burdens, and personal economic impact of those options, such as out-of-pocket costs and other insurance-related costs. However, educating patients on all these relevant issues is critical if we are going to empower them to make the best decisions for their health over the long haul.
Three treatment options; three different patient journeys
To illustrate the diversity of available treatment options for patients experiencing obesity and unhealthy blood glucose, blood pressure, and blood lipid levels, we will explore those options through the lens of a patient living with type 2 diabetes, a common chronic condition largely caused by metabolic syndrome. Today, the three main treatment options are: 1) medication and medical treatments; 2) weight-loss surgery; and 3) intense lifestyle change. Over a series of posts, we will discuss each of these treatment options in more depth. We’ll tackle them in the order they are listed above, which is in descending order of their prevalence of use in today’s healthcare system (medications and medical treatments being by far the most common). The two less common and newer approaches can effectively put type 2 diabetes into remission, but patients must be well-informed and have access to lifelong care and support to stay in remission.
Treatment Option #1: Traditional medication management
Medication management is the traditional biomedical approach and is most frequently offered to patients with type 2 diabetes, even though it does not always achieve optimal outcomes or contain costs. Under this model, the patient is prescribed diabetes medications to move their problematic, out-of-range clinical results back towards normal. This medication strategy is often followed or accompanied by increasingly intense and costly medical procedures to repair damage to hearts, kidneys, eyes, and limbs that is not prevented by medications and medical treatments.
In traditional medication management, clinicians often begin by observing the patient to determine if they are able to make sufficient lifestyle changes to avoid the need for medications. But the patient is typically expected to make these lifestyle changes almost entirely on their own, outside of clinic visits, including changes to the way they eat and drink; their level of physical activity; and reducing their body fat and weight. Although most medical guidelines for type 2 diabetes do suggest lifestyle change as a baseline clinical strategy, in practice, this critical early phase – and window of opportunity to influence the patient’s behavior toward healthier choices – is not given a serious investment of time or effort.
In the traditional medical approach, when a patient is unsuccessful at managing significant lifestyle changes on their own, they are quickly started on the first of several recommended medications from national medication management protocols. There are many classes of diabetes drugs, including: Alpha-glucosidase inhibitors, Biguanides, Bile Acid Sequestrants, Dopamine-2 Agonists, Meglitinides, Sulfonylureas, TZDs, and insulin. Three newer drugs, GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT2 Inhibitors, have more recently become highly recommended in national standards of care. They cost $10,000-$12,000 per year but have shown to provide a degree of heart and kidney protection for some people with type 2 diabetes. Patients may also be prescribed additional drugs for hypertension, cholesterol, or mental health problems by providers over time, which increases the treatment burden for patients.
It is striking to look at a graph of the increase in expenditures on medications from the 1960s to today. According to Statista, in 1960, the US spent $2.7 billion on prescription drugs; in 2020, those expenditures are expected to exceed $358 billion.
Part of this increase arises from innovation and investments made by the pharmaceutical industry to create and market effective new drugs. Some of the growth reflects overprescribing among clinicians. And much of the growth can be attributed to the rapid increase in the prevalence of chronic diseases in the US and our collective failure to address the cultural and societal drivers. The good news is that the medical subspeciality and approach of lifestyle medicine is growing and provides physician leadership and hope in this area.
There is a common and understandable observation made by clinicians that many patients struggle to make lifestyle changes or don’t wish to change comfortable lifestyle habits. (See: “Building a better behavior change model for chronic conditions.”) As a result, medications are often seen as the most practical option for patients. Over time, however, this approach leads to patients being prescribed an increasing number of more costly and more potent medications as the underlying lifestyle issues are not addressed. Diabetes, for example, is deemed to be a “progressive disease” leading to more complications and lower quality of life.
A widespread challenge of the medication management model is that many patients do not properly administer or stick with the drugs that they have been prescribed, which results in patients failing to get the full benefits of the drugs. The slide below by Avella shows this typical low “adherence and persistence” pattern of medication taking nationwide. It shows that a large share of patients with chronic conditions, including type 2 diabetes, stop taking their prescribed medications by 12 months.
4 Cochrane Review, Oct, 2005; Transplantation (2007;83:858-873) Blood (2007;109:58-60)
Although this is a well-documented phenomenon, the obvious question is: why don’t patients take their medications? Why do they fail to pick them up from the pharmacy; not take them at the right time; take them occasionally; or give them up altogether? Because patients often don’t understand why they are taking them, don’t see the value in them, or find them difficult to take consistently. Decades of behavioral research in medication adherence shows that many patients with type 2 diabetes, for example, hold strong personal attitudes, beliefs, emotions, and preferences about medications they are prescribed. These result from beliefs about whether they feel the medications work; whether the patient experiences unpleasant side effects; if the medication is judged costly or inconvenient to keep taking every day; and the emotional impact of the patient realizing that the medications have to be taken for the rest of their life. These intensely personal, psychological issues are practical barriers that need to be carefully understood by clinicians, explored with the patient, and built into each individual’s personalized treatment plan if the patient is to get the full benefits of prescribed drugs and avoid progressing to more aggressive medical treatments.
Providing evidence-based strategies for patients to support their medication taking habits can have a positive impact and improve health outcomes. The healthcare system has been slow to offer patients access to promising, new, relatively inexpensive technologies shown in clinical research to improve medication adherence. Healthcare is a highly regulated industry with many diverse points of view among those who deliver, administer, and pay for patient care. As a result, new options such as smart pillboxes; text message support systems and brief patient reminders or feedback; mail-order drugs; and patient portals have been cautiously adopted.
For traditional medication management to work well and for patients to get the full benefits of prescribed medications, clinical teams need to have meaningful conversations with patients to help them problem solve and create a personal action plan that builds in the patient’s preferences and helps them overcome personal barriers. Today, these conversations rarely happen in busy clinic visits.
At Silver Fern, we want to help clinicians take a more holistic approach to patient care. That’s why we’ve built a module on medication taking into all of our chronic disease programs. Our unique, digital Behavior Diagnostic Platform is a decision support tool that helps clinical teams efficiently understand what facilitates and gets in the way of each patient’s progress. The Type 2 Diabetes Program is comprised of 18 modules on topics essential to holistic care, including medication taking, and enables care teams to explore behaviors, preferences, and psychosocial barriers related to medication taking, which, when illuminated for the patient, enrich the treatment plan and help the patient succeed through long-term engagement.
A holistic, patient-centered approach, informed by patient-generated information, compliments existing clinical care strategies as part of medication management, such as medication list reconciliation or prescribing newer combination drugs that simplify daily dosing for patients.
Adoption of newer technologies and patient-centered strategies, however, must also be supported by well-aligned payment models. We are seeing progress in this area for primary care practices across the US thanks to leadership from the federal government’s Medicare program.
Stay tuned for our future posts on the treatment options for type 2 diabetes. We will explore two evidence-based strategies that aim to put diabetes into remission: weight-loss surgery and dramatic lifestyle change. These options are challenging for patients in ways that are distinct from traditional medication management, but the possibility of freedom from medications, medical procedures, and serious diabetes complications are the worthwhile benefits of these alternative approaches.
Garry Welch, PhD is an expert in the area of behavior medicine for chronic disease care. He has extensive experience leading clinical research on behavior change strategies for people with diabetes and other chronic diseases. Dr. Welch’s 30+ years of clinical research led to co-founding Silver Fern Healthcare. He leads research and development at Silver Fern.