TIME FOR “DRILLING DOWN”

In the ongoing battle against diseases such as diabetes mellitus (DM), we seem to progress through distinct phases. With the discovery of insulin,¹ the view of diabetes changed from one of lethality and suffering to hope and a “cure”.² Soon after, however, and into the middle 1970s, diabetes entered into a “chronic disease phase” with a sense of “inevitability” regarding devastating and deadly complications.^2,3 The National Diabetes Act⁴ and the National Commission on Diabetes⁵ launched a 30 year phase of aggressive pursuit of greater understanding, discovery, and action, with A) emerging evidence of the size and scope of the diabetes burden;⁶ and B) convincing scientific efficacy evidence that both glucose control mattered;^7–9 and that macrovascular disease did not have to happen among persons with DM.¹⁰ The beginning of the 21^st century heralded two additional phases: A) evidence that the “epidemic” of DM is not only large, but still growing and international, and thus indicating an awareness of both individual AND society health and economic challenges;^11–13 and B) convincing scientific and economic evidence that in high-risk individuals at least, i.e. those with “prediabetes,” reduction in the incidence of type 2 DM is possible (if not also desirable and necessary!).^14–16

So perhaps some of the “big picture” of diabetes has become more clear – at least in the scientific, health care, political, private and popular communities:^17–19 on the one hand, DM is a big problem that is likely to get bigger before it gets smaller; and on the other hand, because of the efficacy evidence of the benefits of both improved care and primary prevention, we can, in fact, limit how big the problems of diabetes get and how long it stays big–before returning to baseline.

What does all this mean? Now, with the more general information as described above, it is time to “drill down”– to get below the surface and the “big picture;” to examine all the many and complex factors that will allow the establishment and wide dissemination of the effective care and prevention interventions which address diabetes. In this issue of the Journal of General Internal Medicine are several articles which address various dimensions of “the details” of the management and prevention of DM–how people feel about and function with their DM, as well as the use (or not!) of newer sources of information and knowledge about DM via the Internet;^20–22 how other common conditions very frequently associated with diabetes^23,24–depression and cardiovascular disease – can and do impact on DM itself;^25,26 and why tertiary prevention programs addressing a devastating complication of diabetes such as loss of vision–scientifically and economically validated almost 40 years ago!²⁷–still has not resulted in widely available programs in the United States.²⁸

Of special importance in several of these papers^23,24 is the attention to issues of social justice for populations of Americans already struggling with so much about diabetes²⁹–among many other challenging issues.^30–32

Each article has some limitation–cross sectional in design, small study populations, limited generalizeability, etc. But in the aggregate, they move forward in helping to identify the “deviling details,” which should be studied in subsequent investigations.

This “drilling down”–the efforts to now obtain more understanding below the surface of DM–is important in efforts not just to understand the condition, but to do more things in a better way to attenuate the individual and societal burden of DM ^33,34. We always need to know more, but it does seem that in terms of DM, we know enough to greater and better action ³⁵. The location of this action is quite clear. Will Sutton claimed that he robbed banks because that was where the money was! ³⁶ Likewise, the “diabetes money” is in the hands of the “primary care bank”.³⁷ But it will be the interactions among all the involved parties–primary care clinicians, specialists, patients, policy makers, private and public purchasers of care, communities, etc.–that will result in productive and accountable action.³⁸ Care and prevention programs need to be expanded if ALL persons at risk for, or with DM, benefit.²⁹ The “drilling down” should help immensely in improving any existing or anticipated interventions directed to the burden of DM.