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The Urgent State of Diabetes

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One of the fastest growing epidemics in America, and the world, doesn't have enough health care providers (HCPS). Not even close.

So how are we going to handle the flood of diabetes patients coming at our health care system like a tsunami?

Close to 25 million Americans have diabetes, and amazingly, nearly 25 percent don't know they have it. Almost another 60 million Americans have lined up to get type 2 diabetes; they have pre-diabetes. Most people with pre-diabetes will get type 2 diabetes within five to 10 years if they don't normalize their weight and get active.

Diabetes is the fifth leading cause of death in America; it kills more people than breast cancer and AIDs combined. It ranks number one in direct health costs, consuming one out of seven healthcare dollars. In 2007 the financial cost of diabetes-related doctor visits, medications, hospitalizations, surgeries and treating complications was $116 billion. Adding the costs for lost wages, reduced productivity and disability, the cost is $174 bilIion.

Diabetes is also exploding around the world, in Western Europe and underdeveloped nations, particularly China, India and the Middle East.

China now has more people with diabetes than any other nation, topping the world at 92.4 million. Approximately 26 per cent of the population of Kuwait suffers from diabetes or its implications. The International Diabetes Federation (IDF) estimates that close to half a billion people around the world will have diabetes in 2030 - that's less than 20 years away.

Here's the rub: diabetes requires patients manage the state of their diabetes, and their blood sugar, every day through dozens of informed decisions around medicine, food, activity, stress and sickness. If patients don't know how to do this they will likely get devastating diabetes complications. Given the numbers, we have one diabetes educator, someone trained to work specifically with diabetes patients, per roughly 1,700 patients. If I include patients with pre-diabetes, we have one educator for roughly 5,700 patients.

3 things that are making the state of diabetes worse:

1. Most GPs are not current on diabetes
Most patients see their local family doctor for diabetes. Most GPs had a half- or one-day lecture in medical school on diabetes. Very few are current on the constantly-changing 'Standards of Care' that provide guidelines for diagnosis, medication and all stages of treatment.

To make matters worse, some GPs won't prescribe insulin to their patients, even when necessary, because they aren't knowledgeable about insulin and educating and titrating (dosing) patients on it. And there's little incentive as it's time-consuming and frankly doesn't pay.

2. Not enough endocrinologists for patients
Endocrinologists specialize in hormone imbalances and are the treating specialist for diabetes. According to Andrew Stewart, M.D., chief of the endocrinology division at the University of Pittsburgh, there's an endocrinologist shortage and patients typically wait three to nine months to see their endo, and many endocrinology practices are no longer accepting new patients. "Seen another way," Stewart says, "there are some 4,000 M.D. endocrinologists to care for approximately 25 to 100 million patients who might reasonably wish to be seen by an endocrinologist."

Fewer medical students are going into endocrinology. Chronic conditions like diabetes are a time-thief and a financial drain for endos. Further, despite the need for endocrinologists, the number of training programs in the United States to train M.D.s in endocrinology has declined over the past decade. The Accreditation Council for Graduate Medical Education reported in 2008 that there were 122 accredited M.D. endocrinology fellowships in the United States. In 1996 there were 140.

#3. Not enough diabetes educators for patients
Diabetes educators are on the front lines helping patients learn how to manage their condition. Coast to coast there are only about 15,000 diabetes educators. Now think about how many more are coming -- patients, not educators. Diabetes educators are not increasing in number, and in many areas of the country they are dwindling. Not surprising given the flood of patents, including now children, huge workloads, pay, burn-out and retirement.

Further, becoming a diabetes educator is not easy, there is no direct route. Most of these impassioned Florence Nightingales fall into it. They may be a nurse or dietitian and there's an opening for someone in their clinic or hospital to learn diabetes on the job. We'd do well to create a course curriculum that provides an easier route.

No one will deny we have an exploding population of patients and a dwindling team of health care providers. In fact, the incidence of diabetes around the world is rising so quickly that the IDF, for the first time in 58 years, has decided that beginning in 2011 they will meet once every two years instead of every three.

Find another hospital, no beds available
"I have this picture in my head," said a diabetes educator I interviewed, "of the future where patients come into the hospital with an ailment other than diabetes, and they're lined up waiting in the hallway because all the beds are filled with diabetics."

This week I'll be at the annual conference of the American Association of Diabetes Educators in San Antonio, Texas August 3-8th. Around 6,300 educators who have found the funds to attend will gather to get more credits, learn, bond and get reinspired to continue to do the incredibly important work that they do.

I will be presenting at the conference about a model for improved patient care that includes a new way for educators and patients to work together creating more success for both.

I'll also be checking the pulse of this over-extended workforce and hoping I can report back with some good news.