Diabetes Care: How to Close the Gap Between Where We Are and Where We Could Be


Here: 3 strategies that can help fuel the patient's drive to change.


We’ve seen the National Health and Nutrition Examination Survey (NHANES) statistics about the strides made in improving hemoglobin A1c, blood pressure, and lipids in patients with diabetes in the past 10 years. Yet 33% to 49% of these individuals are still not at goal for glucose, blood pressure, or low-density lipoprotein cholesterol control-and a mere 14% are at the targets for all 3 and are not smoking.1

We’re also well aware of the underlying obstacles, which include economic barriers, problems with access to care, knowledge deficits, and clinical inertia. The last obstacle cuts both ways-for the patient and the physician.

Here’s an example of clinical inertia: the patient has been above goal for, say, glucose. She never brings her self-monitoring blood glucose results to office visits. Her A1c values have been stagnant, hovering at 10.3% or higher. She says, “I’m going to get back on track. I don’t want to go on insulin, so can you give me 3 more months?”

But how do we close the gap between treatment goals-and clinical reality? Here are some thoughts. By no means am I implying that these are the only potential solutions, or that they are easy.

1. Start with the patient
Steve Edelman, MD, is an endocrinologist at the VA San Diego Healthcare System and the University of California, San Diego School of Medicine. He’s lived with diabetes since age 15 and is the founder of Taking Control of Your Diabetes (tcoyd.org), a nonprofit organization that aims to activate patients by providing education in an engaging manner. He’s also one of my mentors.

I remember seeing Dr. Edelman open his patient visits with, “What’s bothering you the most about your diabetes?” or “What’s the biggest issue you’re having with your diabetes?” The next step, although it sounds patently obvious, is not to speak. Even though we’re all time-crunched (allotted 15 to 30 minutes per patient) and often behind schedule, we need to take the time to truly listen. Work with the patient to identify potential obstacles, or points of confusion, and ask the patient to select one facet he or she will focus on changing.

2. Use technology to help
Technology can strike fear into the hearts of both patients and their physicians. (I often fit into this category.) But it should help, not hinder. This could be as simple as using the smartphone that so many of us spend so much of our lives staring at. In addition to surfing for the latest headlines or checking friends’ Facebook or Instagram updates, why not turn a staid, paper logbook into an electronic one? I suggest to patients that they enter readings in the Notes feature or in one of numerous apps. Examples include:
Glucose Buddy3. Provide access to navigators
Here’s where you’ve got to marry high tech with high touch, and it definitely takes a team effort. Nurse care coordinators, certified diabetes educators, health coaches, or a combination of any of these can provide support, encouragement, and advice. These individuals are additional resources who are integral parts of a team and can help augment our efforts at education, troubleshooting, and being there between follow-up visits. Health coaches can be virtual, such as the Cornerstones4Care Diabetes Health Coach.

To me, the key is to ignite the spark that will fuel the patient’s drive to change-and to sustain it. These are just a few of multiple ideas to help patients at an individual level. Please share any insights you have on strategies that have worked for your patients and you.


Dr. Chao does not have any conflicts of interest relevant to any of the products or companies mentioned in this article.


1. Ali MK, Bullard KM, Saaddine JB, et al. Achievement of goals in U.S. diabetes care, 1999-2010. N Engl J Med. 2013;368:1613-1624.

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