Eating a healthy diet and getting regular exercise have enormous benefits for all human beings, whether or not they have diabetes. These should be actively encouraged and promoted at every opportunity. It obviously does not cost patients anything (financially) to change their attitudes and lifestyle habits. However, we need to be aware that it is difficult for many patients to make a substantial enough change in lifestyle, or to sustain it long enough to have a dramatic impact on their future health. For certain subsets of patients, taking medications to lower blood pressure, cholesterol, or modify the inflammatory response inside their blood vessels can dramatically reduce their future cardiovascular risk. Taking pills is much easier for most people than changing their lifestyle. Many powerful and effective drugs are available in generic forms that are within the reach of most patients.

Making "The Business Case" for improved diabetes care will vary depending on how a particular leader, administrator, or manager views the world. At the very least it has been shown that organizing care so that patients with chronic illness get planned proactive interventions does NOT cost more than haphazard, inefficient and disorganized care! For those working in a capitated environment it makes sense to do things that will avoid expensive events at a future date. For those living in a fee-for-service world becoming known as a provider of excellent, coordinated, comprehensive care will attract new business. It would help if the payors and purchasers of health care rewarded organizations who provide care resulting in healthier diabetic patients.

Most doctors want to give great care to their patients. Many of them also think that they are already giving great care and are working as hard as they can. Start by collecting data on how well their diabetic patients are doing in terms of standard measures of clinical quality. How many of Dr. Smith’s patients have had a retinal examination in the past year? How many have a hemoglobin A1c under 7.0%, and so on? Give Dr. Smith feedback on his own patients compared to other providers, and national benchmarks. It is likely that he is doing much worse than he thought. If you then point out that most of his diabetic patients are coming in to see him (or someone else on his staff) six or more times a year you can try to convince him that he does not need to work harder to get improved care, he needs to have his system of care improved so that more of his patients get the correct advice and interventions offered. Make is easier for him (and his staff) to do the right thing. Obviously, it would help if financial incentives rewarded him for providing integrated and coordinated planned care for his diabetic patients.

The greatest risk to the health and life of people with diabetes is developing atherosclerosis at an early age. Many interventions have been shown to have a powerful effect on reducing future risk of cardiovascular events. These include smoking cessation, lowering blood pressure, taking aspirin, angiotensin-converting enzyme inhibitors (ACE-Is) or ACE-receptor blockers (ARBs), statins, eating a healthy diet, getting regular exercise. Improving average blood glucose levels contributes to reducing cardiovascular disease and also slows down or prevents several specific microvascular complications, including retinopathy, neuropathy and nephropathy. When deciding which one or more interventions to focus on in a diabetes improvement project you need to consider several practical aspects of the work. These interventions vary in how complex they are to implement, how expensive they are to patients or to the health system as a whole. It is important that everyone in the organization (from senior leadership and clinic administrators to clinicians seeing patients) become enthusiastic and in agreement about where to start. If there is community support for lifestyle interventions like diet and exercise, with easy access to facilities and staff who are eager to help then this would be a great place to start. However, if none of those things are available in your community but the doctors are all enthusiastic about ACE-inhibitor use then that would be an appropriate priority. Whatever you start with you should try to set up your program so that adding additional priorities will be possible in the future.