Dr. Jon Hallberg: Diabetes treatment goals missed

Fewer than half of Americans diagnosed with diabetes are meeting key treatment goals, according to a study in the latest issue of the New England Journal of Medicine.

About 19 million people in the United States have been diagnosed with diabetes. The study reviewed thousands of cases from 1999 to 2010, including Type 1 and Type 2 diabetes.

MPR's Tom Crann discussed the findings this week with Dr. Jon Hallberg, a physician in family medicine at the University of Minnesota and medical director of the Mill City Clinic in Minneapolis.

Tom Crann: How are we doing with diabetic care in this country?

Dr. Jon Hallberg: It depends on how you look at it. I suppose this is one of those 'cup is half full or half empty' [situations]. We're doing better in some regards, in terms of blood sugar control, blood pressure, cholesterol, some of those goals. But smoking hasn't changed, and even in the best of cases, only about half the people with diabetes in this country are meeting those goals.

Crann: So take us into the clinic. How often are you dealing with diabetes?

Hallberg: In primary care, it's every single day, every single half-day. I mean I know that just based on my numbers, 10 percent of my patients are diabetic, and that really fits with a typical clinic.

Crann: And how do you approach it? What is the treatment like?

Hallberg: If it's Type 2 diabetes, something that's not going to require insulin, at least at first, I think the only way to approach this is to sort of break it apart, because there are so many different factors at play here. You're talking about blood pressure and cholesterol and the sugar levels themselves, and so you almost have to start with one thing, really focus on that, but not losing sight of the other things.

Crann: What makes diabetes such a bad disease?

Hallberg: We all know that it has to do with high blood sugar levels ... It's not that the level that's high is the problem in and of itself. It's over time. It's not today. It's not tomorrow. It's in the big scheme of things, that day after day, having high blood sugar levels, irritating blood vessel linings, that's the problem. So if they have an effect on small blood vessels, that's micro-vascular disease. Then it can affect the eyes, the kidneys, the fingertips and toes. If it's the big vessels, it can cause things like strokes in the brain and heart attacks.

Crann: This study found fewer than half of patients are actually meeting goals for care. Is that a case of, are they getting the right treatment, or is it a matter of the patient following treatment?

Hallberg: I think it's all of that. And ... are people who are diagnosed with diabetes even getting care, are they even getting in the door? So it's an access issue. I think that it's not for lack of trying, that's for sure. And it's funny because we often celebrate in the clinics if we hit sort of 50 percent of our patients are at goal, but that's really sort of sad because 50 percent of the people are not at goal with their care.

Crann: Define that 'at goal' and what it takes for a patient to get there.

Hallberg: There are five main things, especially in Minnesota, that we look at. These are part of the community measures. So you want something called an A1c level to be ideally less than eight.

Crann: That's a blood sugar test, or level?

Hallberg: That's right. It measures your blood sugar, not just at this moment in time like a fasting level, but over the last three or four months. So it gives a really good picture of where it's at. So you adjust that based on the kind of diabetes a person has and their age, to some extent.

You want their blood pressure ideally to be less than 130 over 80, in some cases less than 140 over 90. Their bad cholesterol, their LDL cholesterol should be less than 100. Typically, you want them on aspirin or some sort of an anti-coagulant. And you don't want your diabetic patients to smoke. You don't want anyone to smoke, of course, but especially with diabetes.

Crann: So it's a multifaceted plan. What is so difficult about it?

Hallberg: Each one of those things can be challenging. I think of people with high blood pressure, and [some patients will say] 'I'm on three different medications. I don't want to take anything more. I feel tired on these meds. I've tried to lose weight. I can't do it.' I mean that's just one factor. And we're talking three, four, five different factors in some cases. So it's just, you take all of that together, it's really tricky.

Crann: What is going well in diabetes treatment?

Hallberg: If you look back over the last few decades, we're doing a lot, lot better than we used to do. Blood pressure's under better control. Cholesterol's under better control. The sugar levels themselves are in tighter control. So I mean taken as a whole, that's certainly good news.

(Interview edited and transcribed by MPR reporter Madeleine Baran)

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