The gap between guidelines and practice in the treatment of type 2 diabetes: A nationwide survey in Norway

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Abstract

Aims

In a nationwide sample of patients with type 2 diabetes we assessed the prevalence of complications and compliance with current guidelines.

Methods

We recruited a randomly selected sample of 534 men and 441 women aged 18–75 years with type 2 diabetes. A single visit review of medical records, interview, physical examination and laboratory tests was collected.

Results

The WHO criteria for the metabolic syndrome were met by 79% [74%, 84%]. Thirty percent [28%, 33%] had a history of cardiovascular disease, 13% [11%, 16%] had microalbuminuria, 15% [13%, 18%] had retinopathy, and 23% [21%, 26%] had peripheral neuropathy assessed by a monofilament test. Erectile dysfunction was common (43% [38%, 47%]). Two thirds met the national treatment target for glycaemia (HbA1c <7.5%), one-half the blood pressure target (BP <140/85 mmHg), and one-third the target for lipids (total/HDL cholesterol <4). However, only 13% reached the combined targets for glucose, blood pressure and cholesterol control.

Conclusions

The classical microvascular complications of diabetes affected a minority of participants while the metabolic syndrome affected the majority. The gap between guidelines and current clinical practice was substantial given that only one of eight patients reached the combined goals for glycaemia, blood pressure and lipid control.

Introduction

The prevalence of type 2 diabetes is increasing in many countries [1] including Norway [2]. Patients with type 2 diabetes have a 2–4-fold increased risk of developing cardiovascular disease [3], [4], [5]. Effective lowering of blood pressure and cholesterol decrease the incidence of macrovascular complications [6], [7], [8], [9], whereas active treatment of hyperglycaemia and hypertension reduces the incidence of microvascular complications (retinopathy, nephropathy and neuropathy) [6], [10], [11].

Type 2 diabetes is part of a complex metabolic syndrome, and it has become evident that multifactorial treatment of glycaemia, blood pressure and cholesterol more effectively lowers the risk of cardiovascular disease in these patients [9]. Recent treatment guidelines therefore emphasise the need to treat all three risk factors actively [12], [13], [14].

This study was conducted to assess the prevalence of micro- and macrovascular complications among patients with type 2 diabetes in Norway, and to estimate to what extent national and international treatment goals for established risk factors are being met.

Section snippets

Subjects and methods

The study protocol was recommended by the Regional Ethics Committee and the Research Board of the Norwegian College of General Practitioners (NSAM). It complied with the recommendations of the Declaration of Helsinki. Of 4074 Norwegian general practitioners with more than 900 listed patients, eligible doctors were selected by computer generated randomisation and stratified according to the patient population in each of 19 Norwegian counties (Fig. 1). One hundred and eleven out of 700 eligible

Patient characteristics

In total 975 patients (534 men and 441 women) with type 2 diabetes took part in the study (Table 1).

Prevalence of cardiovascular risk factors and complications from diabetes

are shown in Table 2. Thirty percent [95% CI 28%, 33%] of the patients had macrovascular diseases. Of the total, 79% [95% CI 74%, 84%] met the criteria for the metabolic syndrome.

Treatment of diabetes and complication risk factors

There were no major gender differences in treatment modalities. Diet alone was the only hypoglycaemic treatment in 27% of the patients (259/975), 53% (520/975) used oral hypoglycaemic agents, and 20% (196/975) were

Discussion

We found that some 80% of type 2 diabetes patients had the metabolic syndrome according to the WHO definition [15], and 30% had macrovascular complications. The prevalences of microalbuminuria and retinopathy were low. Two out of three patients reached the national treatment goal for glycaemia, one-half the treatment goal for blood pressure, and one-third the treatment goal for lipid control. One out of eight patients reached the three treatment goals combined.

The patients with the most

Conflicts of interest

This study was supported by Pfizer Inc., Norway. None of the authors have any conflict of interest pertained to this work.

Acknowledgements

The authors thank all 111 participating investigational sites. The authors also thank Hilde Kloster, Smerud Medical Research Norway AS, for assistance with the manuscript.

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