Why Diabetes Outcomes Aren't Improving: System Gaps, Legacy Effect, and What Patients Can Do

Welcome to the Diabetes Blueprint podcast, where Dr. Rangi dives into the realities and urgent challenges of diabetes care, whether you're living with the condition, love someone who does, or work in healthcare. The conversation focused on the critical question: Why are outcomes for people with diabetes not improving, even in an era of advanced science, medications, and expert clinicians?

A key theme that emerged was the persistent gap between evidence-based medical guidelines and the actual care received by patients. The discussion explored heartbreaking examples of individuals whose diabetes complications amputations, strokes, and loss of independence, could have been prevented, highlighting patterns of missed diagnoses, insufficient treatment intensification, and a lack of patient education.

One concept discussed was the "legacy effect," which underscores the lasting impact of early blood sugar control on long-term health outcomes and why timing is crucial in chronic disease management. Several points were raised, including the life-altering consequences of uncontrolled diabetes, ranging from heart attacks to blindness and financial devastation.

This episode sets the stage for actionable solutions, previewing six specific, evidence-based gaps in care that patients and their healthcare teams can address immediately. Listen in to discover why so much suffering is preventable and how understanding these gaps can empower you or your loved ones to advocate for better diabetes care—today, not someday.

00:00 Long-term effects of diabetes

04:04 Fear of needles and alternatives

08:34 Investigating gaps in diabetes care

12:50 Challenges in Diabetes Care

13:58 Improving diabetes education efforts

17:35 Importance of early diabetes control

24:08 Discussing kidney failure risks

27:21 Emotional impact of diabetes

30:52 Understanding CKM Syndrome in 2023

32:51 Research not reaching patients

38:08 Addressing treatment and monitoring gaps

38:48 Benefits of glucose monitoring

42:21 Show sign-off and gratitude

The Metabolic Longevity Quiz -  rangimd.com/quiz 

The Book companion site-  rangimd.com/blueprint —  (MAP checklist, downloadable tools)
 

The Upstream Diabetes Course - rangimd.com/upstream 

ADCC Provider Training- rangimd.com/academy

The Metabolic Longevity Program- rangimd.com/join —  (work with Dr. Rangi directly)

Show Website - https://lowerthedosepodcast.com/

Dr. Rangi's Website - https://rangimd.com/

Podcast Partner - TopHealth - https://tophealth.care/

Dr. Rangi's LinkedIn - https://www.linkedin.com/in/jaiwant-rangi-md-face-32226b97/

“Disclaimer: Informational only. Not medical advice. Consult your doctor for guidance.”

Transcript

SPEAKER_01 0:00

When we have the best signs, the best medications, the best devices, the best trained clinicians in the history of the disease, patients are still losing their limbs, they're losing their sights, they're losing their kidneys. Spite a few major diabetes reports came clear to me that they documented close to almost 50 gaps. One study stopped me called. What it showed was 94% of adults with diabetes were connected to the doctor. What is shocking is only 23% or less than one in four achieved that combined target for what we call as ABCs of diabetes. That tells us something very important. The science is not the problem. The system is the problem. Our system is broken.

SPEAKER_00 1:20

She's recently written a book that I truly believe needed to exist. And it needed to exist because it answers the questions that so many patients are silently asking. Why am I doing what I was told to, but I'm still somehow getting worse? Dr. Rangi, before we get into the data, the research, and the gaps in the system, I really want to start with something personal. So it's a pleasure to see you as always. And I think this is such an important episode. I'm excited for this one specifically, getting a little bit more into the book. But before we get into all of that as well, I really want to know what was the moment that really made you say I have to write this book. Hi Layla. Good to see you again.

SPEAKER_01 1:55

It was not one statistic. It was not one study. It was a patient. A man walked into my office with his son beside him, leaning on a walker, and he had just been discharged from the hospital after more than almost six months. Six months of surgeons trying to save his leg, six months of wound care, six months of complications, and six months of hope slowly draining away. Unfortunately, they could not salvage or save his leg. And when I looked back through his records, the story was written in plain sight. His A1C, the number that tells us how well controlled the diabetes is, had been between eight and eleven for almost a decade or ten years. Ten years of uncontrolled blood sugars. In all that time, his treatment had never truly been intensified. He had not been referred to a specialist. He had not been started on medications that may have protected his heart or blood vessels and kidneys. It was the same prescriptions, the same plan, year after year. And when he would go for his 10-minute visit and bargain with the doctor and ask him not to give him injections or insulin, it would be the same plan again to, all right, let's watch it. Next time we'll be better. But before he knew, it was 10 years. His wound never healed, you know, because his body was damaged inside and because of high blood sugars. And because of the inflammation and the compounding effects of high blood sugars silently over time, the wound took its effect where the surgeons couldn't do much to save it. They started with one toe and then part of the foot and then lower leg, and then eventually he had above knee amputation. Now, this is not something we see all the time, but it is not that rare. I do see few of these cases in a year. I just feel this could have been prevented. This is not something that should have gone to this stage. And then there's another patient, a woman who sat across from me and with her husband, and her A1C had been hovering in 9 to 10 range for years. She had been labeled as having type 2 diabetes. But when I tested her antibodies on a sample of a blood test, they were high or positive. She did not have ordinary type 2 diabetes. She had autoimmune diabetes that looked like type 1 from outside on the surface, but it behaved like type 1. What does that mean? This means she needed insulin. But she was afraid of needles. So instead of solving that fear that she's afraid of needles, the system accommodated it. You know, wanted to just work with her with the pills she's asking for. She could have been given inhaled insulin, she could have been offered the best insulin pump therapy. Other options exist, but no one had offered those to her. And it was labeled that I do not want injections, and let's just work with what you have. That day, almost casually she told me that Doc, since the last couple days over the weekend, I have lost vision in one eye, in the left eye, but it comes back, you know, a few seconds later. And very casually she says, Well, by the way, I just wanted to let you know, but I have an eye doctor's appointment a month from now. And of course, to me that was not settling, and it sounded like she needs urgent care right now. She needs emergency care because that was a sign of TIA or trans ischemic attack, which is usually the early presentation of stroke. So I did not wait. I sent her to the emergency room immediately. Unfortunately, within the next 24 hours, she had a massive stroke while she was in the hospital. When I saw her after discharge, she was in the wheelchair, her husband completely changed. Depression, grief, exhaustion, resentment have entered the home that was once full of life. And what broke me open was not these two patients, it was a pattern. I kept seeing the same story over and over again. Heart attacks, strokes, kidney failure, blindness, amputations in patients who were already in the system. These guys were already seeing the doctors. They had prescriptions, they had doctors, they had appointments, and still the outcomes were not changing. So, of course, that was a moment when I felt we need to do something different. We need to educate more, bring awareness, and that's where my journey started for writing the book.

SPEAKER_00 6:32

Wow, and I think that with these outcomes that seem like you said you mentioned a pattern and they're not changing. I guess the main question would be why? Why is are they not changing?

SPEAKER_01 6:43

Yeah, Leila, that's a great question. When we have the best signs, the best medications, the best devices, the best trained clinicians in the history of the disease, patients are still losing their limbs, they're losing their sights, they're losing their kidneys, and losing the years of their lives. That is a question that led to me writing the book.

SPEAKER_00 7:04

And then, so before we go into this further, I want to pause for a second for our listeners, because there is so much diabetes advice out there right now, right? Between social media advice, influencer advice, wellness trends, diet wars, supplement claims, miracle promises, if you will. So what makes this different?

SPEAKER_01 7:23

Layla, this is not a trend. It is a personal opinion. It is not what worked for one person on the internet. You know, usually you'll see influencers talking about their experience or their personal opinion. What I'm talking about is every major claim in the book and everything that we are discussing in these episodes in this podcast is based on published, peer-reviewed, evidence-based signs, some evidence used by the world's leading medical experts or organizations to write the diabetes guidelines. I'm not just asking people to trust me blindly. I'm asking them to understand the signs, see the gaps, learn how to protect themselves, and before damage becomes irreversible, because there's a lot we could do here.

SPEAKER_00 8:09

Absolutely. So so once you really started asking why and you went to the evidence, what did you find specifically?

SPEAKER_01 8:17

Yeah, Lena, so what I did was I I tried to look for this answer, you know, that in spite of the best science and the best evidence, why are the guidelines that are created by these organizations not getting to the primary care providers or to the real ground level medicine that is practiced every day? And we're not talking about academics and institutions. They have a complete team of people who can take care of these patients, and the outcomes even there are not as robust. I'm talking about tertiary care clinics in the community. So, what I did was I wanted to learn where is a mismatch here. You know, when we have the best science and when we have the great guidelines, why aren't they not translating to patient care? And what are we missing here? So I reviewed major diabetes reports, the position statements from last decade, from American Diabetes Association, from European Association of Study of Diabetes, from American Heart Association, World Health Organization, and even the commission created by United States Congress to examine why diabetes outcomes are not improving. So together, after learning from everywhere, it became clear to me that they documented close to almost 50 gaps or separate gaps in diabetes care. So it is not something that if I'm observing it, I'm of course not the first one. It's been observed, it's been documented, and they understand there are at least almost 50 gaps or more. 50 places where the system is breaking down. So no matter how good science is available, if the system is not working, it's not going to translate into better care. But one study stopped me in cold. You know, it looked at the entire chain of diabetes care in the United States over 12 years, and that was from 2005 to 2016. What it showed was 94% of adults with diabetes were connected to the doctor. So which is great. You know, it's not that these we don't have access, you know, these patients have access. They're going to the doctors. That sounds reassuring. You know, it sounds like the system is working because the patients are connected to the doctors. But what is shocking is only 23% or less than one in four achieved that combined target for what we call as ABCs of diabetes, where we call A is A1C, B is blood pressure, C is cholesterol. And we also add smoking to that. So what they looked at in this place was ABCN non-smoking. So just imagine 94% of the population has access to doctors, but 23% of them had achieved the goal, or even less than one in four. And here's the part that should concern everyone. The number did not meaningfully improve over an entire 12-year period. So it's not that we are saying that it was there in 2005 and over time we saw it better. So the patients were in the system, they were seeing the doctors, they were given prescription medications, but the outcomes were not changing. And that's what I wanted to bring attention in my book. The more recent global analysis showed the same pattern again around the world. Previous one was just in the United States. Even among the patients receiving the treatment, only about one in five achieved optimal blood sugar control. That tells us something very important. The science is not the problem. The system is the problem. Our system is broken. It does not work. The care is not, the best science is not getting translated to the best care for the patient.

SPEAKER_00 11:49

And you mentioned the system. So when you say the system, what do you mean by that exactly? Because I think many people hear that and assume that if they have a doctor and they're taking medication, then they should be covered. But I think that that's not quite the case.

SPEAKER_01 12:03

Yeah, system is complex. It's not easy to explain. And being covered and insurance and that all that part is an illusion. It's something that we have to be cautious about. Having a doctor is not the same thing as having a plan. And having a prescription is not the same thing as having the right prescription. Diabetes care fails at the connections. It fails between the diagnosis and the right diagnosis. You know, they may get generic diagnosis of type 2 diabetes, maybe they have certain subtype of type 2 diabetes, or they may have completely different kinds of diabetes that may require different treatment. There's also a gap between research proven and what patients receive, between guidelines recommended and what happens in the rushed exam rooms in 10 minutes, and between lab results and what actual strategy we use for the patients, and between prescription and long-term protection. You know, we don't want to just write prescription at each visit. We need to have a longevity plan for that patient. How are we going to bridge that gap where we say diabetes affects the lifespan? How can we bring it to as normal as possible? What medications can we use or what strategies can we use? So fewer than 10% of people with diabetes ever receive a structured diabetes education. I think that is the simplest thing we can offer. Diabetes education. Among Medicare patients, only about 5% receive diabetes education in the first year. So that is something we can easily take care of. The more we educate the patients, the better they know what to expect, how to take care of themselves, what to expect from their doctors or their care, and from their body. Not because the patients refused it, the 5% that we're talking about in Medicare population is because they were never offered, because many were never told it even existed and never referred, never given the roadmap. So I think there's a lot of things in the system where we could do better.

SPEAKER_00 14:04

Absolutely. 5%, I mean, that's a shocking statistic to really hear. And I think we all should take a second and really sit with that, especially the listeners, because five percent is such a small percent. So I think one of the most important tools in diabetes care that you mentioned, and most people need to know, is that something we just never really hear about. And I think that that's why this conversation is also so important. And I know that something that you do talk about in the book is called the legacy effect. So I had never heard of this before. I'm sure a lot of our listeners hadn't heard this either. So it really, I know for me, it changed the way I think about chronic disease. So can you explain it in plain language?

SPEAKER_01 14:43

Yeah, Leila, the legacy effect is something very important that we must talk to patients earlier on in the disease and throughout, but more important in the earlier times, because that's when it matters the most. Legacy effect is one of the concepts in diabetes that patients have never been taught. Once you understand it, you never look at the blood sugar the same way again. So the damage caused by years of uncontrolled blood sugar does not immediately disappear just because your blood sugars have improved later. So I see a lot of patients who will say, but doc, I used to be high before, now my numbers are so much better. You know, it echoes forward. You know, think of it like water damage in the house. You know, you can fix the leak, that is important. But the damage that happened while the water was running, the wet floors, the moistness inside the walls, the weakened foundation, and the damage may already be there. To prevent all that, we need to have better control to begin with. You can stop it from getting worse, you can repair some of it, but you may never be able to fully undo the damage that has happened with that running water. So that's what happens exactly with the uncontrolled diabetes as well. The proof comes from the longest running diabetes studies ever conducted, where the researchers followed these patients for decades, and here's what they found. The patients who achieved good blood sugar control early in the first years after the diagnosis had dramatically better outcomes, not just during the study, but even for decades afterwards. So the good control early goes on for years later. Even after when their blood sugar numbers became similar to the group that had poorly controlled diabetes in the early control, they continued to do better. So those early years is what we're talking about in legacy effect. The early years left a protective legacy for years to come, if that makes sense. You know, early good control reduced the risk of death, heart attack, complications affecting the eyes, the kidneys, and nerves, and those benefits persisted for years. You know, but the reverse is also true. Years of poor control can leave damaging legacy. So, in other words, the body remembers, the blood vessels remember, the nerves remember, the kidney remembers, the eyes remember, the heart remembers. This is why timing matters so much. If you are good to your body, the diabetes isn't a better control, it will go a long way. If it's bad, it will again there'll be consequences. So the legacy effect is in simple language telling us you don't have room to take it easy. You've got to have good control from earlier on when the diagnosis is made.

SPEAKER_00 17:24

Absolutely. It sounds like timing really does matter so much. So when you think about the two patients that you had described earlier, their legacy had already been ridden for years before anyone stepped in. Is that fair to say? Exactly.

SPEAKER_01 17:37

Yep. The man with the amputation had dangerously high blood sugars for almost a decade. And by that time, the wound appeared and the damage to his blood vessels and the nerves had already been building for years. No surgery could have undo the 10 years of poor control that had written into his body. You know, the woman with the stroke had years of uncontrolled blood sugars, the wrong diagnosis, and the wrong treatment strategy. By the time the stroke happened, the damage had already been accumulating silently in both of them. That is why the message is urgent. Every year matters. Every year of uncontrolled diabetes matters. Every year without right diagnosis, right monitoring, right medications, and right education matters.

SPEAKER_00 18:22

That is definitely, I feel, like that's heavy, but it's also definitely so empowering, and it really does stress how timing is so important. And I think it also means that what someone does now really, really matters as well. Not 10 years from now, not after complications appear, but now currently.

SPEAKER_01 18:40

Exactly. The legacy effect is not just a warning, it is call to action. The earlier you act, the more powerful the benefit is. The window is opened right now. The goal is to walk through it before the damage becomes harder to reverse.

SPEAKER_00 18:55

Absolutely. And before we get into the solutions, which we will cover in the next episode as well, I do want to make sure that the listeners really understand what is actually at stake. So in the book, you lay out 10 consequences of uncontrolled diabetes. And I want to say this clearly. So we are not sharing these to scare people or anything along those lines. We're really just sharing this, these ideas and these thoughts because people really do deserve to know what is at stake before the damage happens. And I think that that's why this conversation is so important because a lot of people simply just don't know, going back to the lack of education. So can we walk through them step by step?

SPEAKER_01 19:33

Absolutely. And I want to say this up front these consequences are not inevitable. That is a most important point. We know how to prevent most of them. The tools exist, the medications exist, the evidence exists, the science is there. So as you listen, do not hear this as a death sentence or something that you can you have no control over. You have all the control. We just want to make sure we keep the diabetes under excellent control. Hear it as a reason to act. So let's talk about different possible complications. The first one is life-threatening consequences. We know this. Lost years are known with diabetes because this puts everything in perspective. Large international studies have shown that people with type 2 diabetes have shortened their life by years, not just months, years. Someone diagnosed at the age 30 may lose more than a decade of life expectancy. Diagnosed at age 40, the loss is still significant. And diagnosed at age 50, the impact is still measured in years. And these are not abstract years. These are years with our children. These are years with your grandchildren. These are the years in your retirement, in your years of independence and years of life. And then there's heart disease. Not diabetes itself is the way that people often think of it. But what diabetes does to your heart and the blood vessels over time is what we are bothered by. People with type 2 diabetes have much higher risk of heart disease than people without diabetes. As the blood sugar rises above goal and heart attack risk rises with it. And then these are there, there's stroke. We already talked about that. Diabetes significantly increased the risk of stroke. And the woman I described earlier is not an isolated case. That pattern plays out every day in the hospitals across the country.

SPEAKER_00 21:24

And for those listening, if you're driving or walking, folding laundry or just listening between appointments, I definitely want to pause on this because this is crucial and everyone really needs to hear this. So heart attacks, strokes, lost years, they're not small risks. These are life changing risks. And it's so important to really make sure that you're paying attention to it and again be very aware of the timing of things as well.

SPEAKER_01 21:50

Yeah. Layla, no, let's talk about the complications that may not affect the life immediately. These are not life threatening, but they can completely change how someone lives, you know. Number one is kidney failure. Diabetes is a leading cause of kidney failure in the United States. It often begins silently years before the symptoms appear. Patients may feel fine while the kidney damage is still already progressing. And without aggressive prevention and treatment, the kidney disease can progress to dialysis three times a week, for hours at a time, and often for the rest of person's life. So that completely changes life. The next one is possible amputations. More than 150,000 amputations are performed every year in the United States in people with diabetes. Now these are not because of accidents, because of diabetes-related nerve damage, poor circulation, wounds, ulcers, and infections, because they cannot mount the healing well. Now it damages the tiny blood vessels in the back of the eyes gradually, and many people do not know it's happening until the damage is advanced. And then there's nerve damage. This affects a large percentage of people with diabetes over their lifetime. It can cause burning on your feet, uh, it can cause numbness, tingling, weakness, balance problems, or loss of sensation in your feet. So sometimes we get people who hurt and they don't even feel that they got hurt, and that's why their wound happens because they didn't feel the pain and now it gets worse. So loss of sensation is dangerous. A person may, like I said, step on something and develop a small blister or a small cut and not feeling it, and before we know it becomes an ulcer and also becomes infected, and that leads to hospitalization. And in extreme cases, if the circulation is not good, then amputation is the answer.

SPEAKER_00 23:42

That is so interesting to really hear how many things can really, I guess from my perspective, not even seem like it may be related to diabetes. There's so much that is really affected. And I think that, for example, kidney failure, amputations, blindness, nerve damage, like you mentioned, they're really not rare. They're distant complications. They're actually pretty common. And many people don't realize how common they are until themselves or someone they love is really already in that moment, already facing them. It's interesting to really hear this for sure.

SPEAKER_01 24:13

Definitely. And then these are there are other consequences that we haven't touched so far. And these are something that can affect your quality of life. You know, it's not life limiting, it's not something which is going to give you serious complications, but something like dementia. You know, diabetes increases the risk of dementia, especially vascular dementia, the type related to the damage of the small blood vessels inside the brain. So diabetes does not only threaten the body, it threatens your memory, your cognition, independence, and your identity. And then there's depression, an emotional burden. You know, that that is something that we don't even talk about as much because there's so much more to address in the practice because patients are having high blood sugars or heart problem that we end up spending more time on that. And here you have, you know, white elephant in the room where you have memory issue or or uh, you know, depression. Uh about one in four people with diabetes experiences clinical depression. Diabetes distress is even more common. That constant emotional weight of checking numbers, taking medications, worrying about food, you know, fearing complications, and feeling like you're failing even when you are trying. You know, I I don't want to sound pessimistic, but these are the things some of the patients live every day. And that's why you need to have a good team. You need to work with someone who can help you the holistic care and who can give you a bit bigger picture and do address all these concerns. And here's the cruel cycle. The depression makes the blood sugars harder to control, and uncontrolled blood sugars make depression worse. And the patient gets blamed for both. And then there's financial devastation. Diabetes is one of the most expensive diseases in America. The cost is not just the healthcare system, it is also to families. It is medications, devices, doctor visits, hospitalizations, lost work, caregiver strain, you know, transportation, insurance battles, co-pays, deductibles, time, you name it. You know, for many families, diabetes becomes a financial disease as much as a medical one. Absolutely.

SPEAKER_00 26:20

That's it's that's a vicious cycle as well. So let's recap these 10 again. So lost years, heart attacks, strokes, kidney failure, amputations, blindness, nerve damage, dementia, depression, financial devastation. That is what uncontrolled diabetes can cost. And it's that's a lot to really take in. I'm I'm a little bit taken back when you're really processing all of this. But I definitely want to bring us back to something that you said earlier because I don't want anyone listening to this and feel hopeless. Because, like you mentioned earlier and even in previous episodes as well, that most of this is preventable. And I think that that's really important to reiterate at this point for sure.

SPEAKER_01 27:01

Yes, Leila, most of this is preventable. You heard it right and you said it right. The landmark diabetes trials show that bringing blood sugars under better control dramatically reduces the risk of eye disease, kidney disease, and nerve damage. Even 1% reduction in A1C can reduce the risk of diabetes complications. But diabetes care is not only about blood sugar. When we address the major risk factors together, the blood sugar, blood pressure, cholesterol, kidney protection, smoking, weight, lifestyle, and the right medications, the outcomes change. So that's why the diabetes visits are very complex. We are not just addressing the blood sugar, but we're addressing everything that affects diabetes, and we call that cardiometabolic disease for a reason, because it affects all the other cardiometabolic factors that work on our heart. So blood pressure, cholesterol, kidney protection. We will be talking about CKM syndrome as mentioned by AHA in 2023, where they have talked about diabetes being a cluster of a problem where it's always cardiac, kidney, and metabolism together. And of course, the weight and the lifestyle and the right medications. So these studies showing us that when the major risk factors are brought to target, when we get them all of them under control, the excess risk of heart attack can be dramatically reduced. And in some groups, nearly eliminated. And that's huge. That is what people need to understand. They should not be scared with the uncontrolled, but they need to see this hope, how much they can prevent. The tools to prevent the suffering already exist. We have the best medications, we have technology that exists, we have education that exists, we have guidelines that exist, we have knowledge that exists. The tragedy is the system is consistently delivering them to people who need them, not at the right time. And that is why understanding the gaps matters, you know, because every gap in the system is measured, not just by percentages, it is measured by the lost years. It's measured by the lost limbs, the lost sight, the kidneys, the independence, and the lives.

SPEAKER_00 29:11

Absolutely. And something that you say pretty bold in the book is you directly address the major medical societies. So the American Diabetes Association, the American Heart Association, the American College of Cardiology, the European Diabetes Organizations, to name a few, and I know there's others that you name as well. So what is your message to them?

SPEAKER_01 29:32

Yeah, Leila, first I say it with deep respect. The research produced by these organizations is extraordinary. The science has never been stronger. The guidelines have never been more advanced. Most people who create them, they work in organizations that are in academic centers. And they're working very hard to improve the care. So I do acknowledge all that. But the question I hope this book raises for every society, institution, policymaker, clinician, and health system is this. What good is the best research in the world if it is not reaching the patient? What good is the guideline if it is never making it to the prescription pad? What good is a recommendation if the patient never hears it? And what good is a breakthrough medication if the person who needs it the most is never offered it or not covered because of prior authorization problems? When less than one in four patients achieve combined targets after years of tracking, the research is not reaching daily care. When patients with heart and kidney risk are not receiving organ protective medications, the guidelines are not reaching that example. When only a small fraction of patients receive structured diabetes education in the first year after diagnosis, remember we talked about less than 5% in Medicare patients in the first year, the recommendations are not reaching the people who need them the most. The gap between the evidence, what the evidence proves, and what the patients actually receive is a defining failure of modern diabetes care. And I want to be very clear, it is not patients' fault. And it's not the society's fault. They've done their best to create the best treatment plan or suggestions or guidelines. But as a community of medical providers and as a system, we need to understand that is not translating to patient care at the ground level. So we need to do something different.

SPEAKER_00 31:33

Absolutely. And I think that it's fair to say that this is what your book is really trying to bridge, correct?

SPEAKER_01 31:38

Exactly. You know, that's what my hope is. That's what I'm trying to do. The book is built on evidence. It's tested in real clinical practice and written for people with system that the system has failed so that people can understand how they can better take care of themselves and be their own advocates so they can ask and expect the best care. It is meant to for patients to help them ask better questions, reorganize the gaps earlier, and become active partners in protecting their future.

SPEAKER_00 32:07

Absolutely. So today we really established the problem. The system is broken, the consequences are devastating. The legacy effect means timing really matters. And the evidence shows that much of the suffering is, like we talked about, preventable. And I think that is a very big key takeaway from this episode as well. And in the next episode, we're gonna talk a little bit more about the solution. And you identified six specific gaps that patients can actually do something about. Not someday, not after policy change, but right now. So, Dr. Rangi, before we get into it in the next episode, can you give us a bit of a preview of what that would look like?

SPEAKER_01 32:44

Yeah, Leila. So after looking at those almost 50 gaps that I was talking about, I decided to pick on what I can work on. And those were six gaps that I identified. And these six have a special reason why I picked those. Why? Because they're backed with strong evidence. They have been clearly documented. They have high leverage. In other words, if you make a small change, it can multiply the benefit. The meaning closing them can improve various outcomes at different levels. And last, third reason to pick these six gaps was because these are patient actionable. Patients can understand them, they can follow them, and it can be used in daily practice. You can do something about them. So again, I'll say the six that I picked are because of three reasons. One, enough evidence is out there that they are missing. Number two, there's enough, it's high leverage. That means a small change can make multiple effects or outcome changes. And most important, these are patient actionable. So what are these gaps? Six gaps. Number one, diagnosis gap. Patients are sometimes not getting the right diagnosis. 40% of type 1 diabetes gets misdiagnosed as type 2. Remission gap. You know, patients need to be taught earlier in the disease stage that if you take enough steps, then we can put your diabetes to sleep or bring you in remission instead of just ongoing medication treatments or prescriptions. Then the third is protection gap. Protection gap is patients who need the cardioprotective medications like GLP1 aginis and SGLT2 inhibitors don't get it. And that could be offered to all the patients who will benefit from them. The fourth is the monitoring gap, continuous glucose monitor. We all know that it records your blood sugars every minute or every five minutes, depending on what kind of monitor you choose. But that should be offered more liberally to most patients with type 2 diabetes. We have insurance barriers, we have patient barriers, they don't want to wear something, but this is huge. I do want to talk about continuous glucose monitors because they help you modify your lifestyle. You know, if you wear a continuous glucose monitor, it tells you when your blood sugars are going high after eating certain substances, food items, and then if you go for a walk, how the blood sugars drop afterwards and what kind of food items are raising it more. It can really teach you what to avoid and how to improve your lifestyle. So I'd really encourage that monitoring to be better, and that is a gap that we have. All the patients who could benefit are not getting that care. But the fifth is education gap, and that's exactly what we're doing now in the podcast and in the book. We're educating people. And the last one is system gap. System gap is where we give fragmented care. And that bothers me because a few times I have been a patient for some reason or the other, and it is frustrating as a patient when you have to go to one doctor for something else and another doctor for something else. And you know, you become the best experts, and we have the best cardiologist in town. We have the best kidney doctor in town. But for patients to go to all those places, it's not easy. It's it's a lot of mental burden. It's a lot of uh, you know, the calendars are full. I have some 70, 80-year-olds who are always writing down, you know, doc, you were the highlight of my week. This week I only have one appointment. You know, next week I have two appointments. I mean, that's not what we want to live for. So the system gap is my sixth gap that I'm talking about. Each comes with a specific question you can ask your doctor in my book. Each one maps to a specific part of the diabetes blueprint. In the book, I have solutions for those six gaps that I have mentioned. And each one, when closed, can change the trajectory or outcomes of your diabetes.

SPEAKER_00 36:24

And that's something that we're definitely gonna get into next time. And if today's episode really made you think, the next episode will definitely help you act. And I can't wait to get to that next episode for sure, Dr. Rangi, and really dive into more about your book as well. And for all the listeners, thank you for listening to the Diabetes Blueprint podcast. We'll see you on the next episode. And remember to learn more about Dr. Rangi's upcoming book, The Diabetes Blueprint, visit Rangiemd.com backslash blueprint. And remember, diabetes is not just about lowering a number, it's about protecting your heart, kidneys, brain, eyes, nerves, independence, and future. Thank you so much. Make sure you are following the show and subscribe. And Dr. Rangi, it's a pleasure to speak with you as always. I can't wait to speak with you soon.

SPEAKER_01 37:06

Thank you, Leila.