Diabetes is generally the most expensive and fastest growing therapeutic class within the majority of corporate drug benefit plans. It presents a huge population health problem and affordability challenge. Yet, we are wasting ever more billions of dollars overtreating Americans with respect to diabetes and obesity.
All this and more are explained by John Abramson, MD, of Harvard Medical School in his seminal book, “Sickening: How Big Pharma Broke American Health Care and How We Can Repair It” — an eye-opening read I highly recommend.
As Dr. Abramson points out, we are making decisions based on pharmaceutical manufacturers’ sales and marketing efforts more so than objective and verified clinical evidence. Please take a moment to review some of these takeaways from Chapter 4, “Insulin Inc.: The Exploitation of Diabetes”:
The Hemoglobin A1c treatment threshold of 7 percent was driven by Aventis (now Sanofi) and the marketing firm Burson-Marsteller via its Aim-Believe-Achieve campaign. This campaign led to the Bridges to Excellence initiative to reward physicians for managing more than half of their diabetic patients to results at or below a HbA1c value of 7 percent. Yet, the Diabetes Quality Improvement Project founded by CMS, ADA and NCQA established the standard of “poor control” at 9.5 percent or more. Convincing the market to adopt lower treatment thresholds enables drug manufacturers to sell more drugs.
As of 2018, five large, randomized trials of type 2 diabetics revealed that tightly controlled blood glucose levels (7 percent or below) did not reduce death, heart attack, stroke, loss of vision, renal disease requiring dialysis, or painful diabetic neuropathy. All five studies linked this more intensive control of blood sugar to more complications and even death in the ACCORD study. Overtreatment is harmful.
Pharma also convinced the market to switch from animal-based insulin (which had been working successfully for over 50 years) to bioengineered human insulin. Based on a gold-standard independent review by the Cochran collaboration, there was “no ‘clinically meaningful differences’ between the two types of insulin for people with type 1 or type 2 diabetes.” However, the drugs did produce economically meaningful results for Eli Lilly and Novo Nordisk.
Second generation bioengineered human insulins, called human analogs, likewise were independently deemed in Cochran Reviews to produce “clinically unremarkable” results for type 1 diabetics and to be “almost identically effective” for type 2 diabetics. More expensive (about 11 times more) and more profitable, but not more effective.
Now, factor in that we have an affordability issue for health plan members and plan sponsors. Dr. Abramson brings this reality to life in the beginning of this same chapter with a tragic episode of a young man that could not afford the higher cost insulin, failed to keep up with the treatment, and died an avoidable death.
Where are we today on this issue? The same two manufacturers that produced highly effective insulin from pigs 100 years ago have upped their games to convince America that we now need GLP-1s to treat diabetes, obesity, and other comorbidities. The dramatic rise in diabetes parallels our dramatic rise in obesity — twice the average of other OECD countries.
As Dr. Abramson points out in the same chapter, the definitive study showing how to reduce the incidence of type 2 diabetes was publicly (not commercially) funded by the Diabetes Prevention Program Research Group and it randomly assigned more than three thousand people at high risk of developing diabetes to one of three groups:
- standard lifestyle recommendations plus placebo
- standard lifestyle recommendations plus metformin (a blood-sugar lowering medication)
- intensive counseling about healthy diet, exercise and behavior modification plus placebo
All participants had prediabetes and two-thirds were obese. The study was highly unusual in that its goal was to determine the best way to decrease the risk of diabetes instead of just trying to prove the efficacy of a particular drug. And the results were counter to what Big Pharma tells us.
After three years, the intensive lifestyle intervention group lost an average of 12 pounds and significantly increased their exercise levels. Furthermore, the randomly selected group intensively counseled on diet and exercise reduced the risk of developing diabetes by 58 percent compared to the placebo group, and by 39 percent compared to the group treated with metformin. All without the risk of serious adverse side effects.
Per Dr. Abramson, between 1996 and 2013, the cost of treating diabetes rose by more than any other disease category, with two-thirds of this increase coming from medications.
Bottom-line, Big Pharma has been selling us ever higher cost and dangerous medications to treat a condition that was effectively and inexpensively treated with animal-based insulin 100 years ago. Maybe it’s time we start focusing our attention upstream on prevention (food supply and physical activity) instead of ever more dangerous and expensive treatment strategies.