Closing the System Gap: How Patients Can Navigate Fragmented Diabetes Care

Welcome to the Diabetes Blueprint podcast, where we dig deep into the realities and obstacles of diabetes care. In this episode, host and endocrinologist Dr. Rangi to unravel what she calls the “system gap”—the missing link that connects and complicates all other gaps in diabetes management, from diagnosis to remission, protection, monitoring, education, and beyond. Despite 94% of adults with diabetes in the U.S. being connected to healthcare providers, only a small fraction achieve their health targets.

Dr. Rangi breaks down how fragmented healthcare leads to missed opportunities and preventable complications. You’ll hear patient stories, learn about the six critical gaps in diabetes care, and discover practical questions you can take to your next appointment to become your own advocate your own “quarterback” in navigating diabetes management. If you or a loved one lives with diabetes, this episode offers straightforward education, empowering strategies, and a fresh way to approach your health journey.

00:00 Discussing the system gap in care

05:10 Discussing a patient's diabetes journey

08:54 Patient self-advocacy in healthcare

12:06 Advocating for Your Health

16:10 Missed opportunities in patient care

20:32 Managing early and late diabetes

23:49 Book release details and health advice

25:33 Managing diabetes lifestyle and education

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

Your blood sugar, your heart, your kidneys, your weight, blood pressure, cholesterol, blood vessels, they are not separate problems. They're all talking to each other all the time. They are all one connected process. But here's the problem. Our healthcare system does not treat you as one connected person. So is the blood sugar well controlled? Is the blood pressure under at goal? Are the kidneys protected? Is the heart protected? That is a system gap where we are not able to coordinate it all together in one cohesive manner.

SPEAKER_00 0:53

In your book, you describe six major gaps in diabetes care: the diagnosis gap, the remission gap, the protection gap, the monitoring gap, the education gap, and finally the system gap. What really stood out to me is that the system gap really seems to connect all the others. And here's a statistic that really stopped me in my tracks. So 94% of adults with diabetes in the United States are connected to a healthcare provider. Yet only 23% achieve the three key health targets, the ABCs, known as the A1C, blood pressure, and cholesterol. In your book, you describe the disconnect as the system gap, the sixth and perhaps the most important gap because it influences everything else. So today we're really going to unpack what the system gap really is, why it matters, and most importantly, what patients can really do to navigate it and improve the outcomes. And Dr. Rang, it's great to see you as always. I know our last episode, we touched a bit on this, so I'm excited to really dive in a little bit deeper today.

SPEAKER_01 1:46

Yes, Leila, you're right. In many ways, the system gap explains why all other gaps exist in the first place. And I'll reiterate the other gaps are the diagnosis gap, the remission gap, the protection gap, the monitoring gap, the education gap. And we are taking care of the education gap right here by educating people and by educating providers. But the system gap is something that ties up everything, and we'll try to touch base on that today. Our body is one connected system. It's not, you know, the head is separate and the heart is separate. You have everything that is connected. And your blood sugar, your heart, your kidneys, your weight, blood pressure, cholesterol, blood vessels, they are not separate problems. They're all talking to each other all the time, right? So the modern medicine is finally beginning to recognize this. In fact, American Heart Association, one of the most influential medical organizations in the world, now formally uses a term called CKM syndrome or cardiovascular kidney metabolic disease, because diabetes, heart disease, and kidney disease, and weight or obesity, metabolic dysfunction are not isolated conditions. They are all one connected process. But here's the problem. Our healthcare system does not treat you as one connected person. You know, it treats all these as separate organs. You see a nephrologist for your kidneys, you see endocrinologist for your blood sugars or diabetes, you see a primary care doctor who has 15 minutes to try to coordinate everything, and you see a cardiologist for your heart and so on. So often no one truly connects the dots. You know, when I see patients in the practice, I will do what I can do best, but it's not a team effort at that point. For patient, he has to go to each an individual specialist. So is the blood sugar well controlled? Is the blood pressure at goal? Are the kidneys protected? You know, is the heart protected? Is a patient on the right medications? And is a plan working? Are we changing the course when the numbers are not improving? That is a system gap, you know, where where we are not able to coordinate it all together in one cohesive manner.

SPEAKER_00 4:01

So it's not just that one thing is being missed, it sounds like it's that really no one is watching the whole entire picture.

SPEAKER_01 4:07

Yeah, we can say that, and I don't want to downplay our primary care providers because they work really hard to take care of this. They are watching it, but it's hard because they may not receive the reports from other specialists, they may not have all the information that the isolated specialists are doing at certain time. There was a major study that tracked the entire chain of diabetes care in the United States over a 12-year-old year period. It was from 2005 through 2016. And what it found was 94% of adults with diabetes were connected to a doctor. And that sounds very reassuring, right? Because everybody has access to the doctor, or at least 94%. But yet, like you mentioned, only 23%, less than one in four, achieved the combined target of blood sugar, blood pressure, cholesterol, and non-smoking. And that number did not meaningfully improve over the entire 12-year period. It's not that we were not doing well and now we're doing much better. It stayed the same. That is system gap in one number. The system does not fail only at one point. It fails in the connections between points. And I have seen this in real life. A man who came to see me with his son, we discussed him in the previous episode. He was leaning on a walker. He had just been discharged from the hospital after more than six months. Six months of surgeons trying to save his leg, six months of wound care, six months of complications, they could not save it. And when I looked back through the records, the A1C had been eight to eleven for almost ten years. And he was in the system, he had the doctors, he had prescriptions, he had appointments, but no one was looking at the whole big picture and asking, why is the blood sugar still dangerously high after years? Why has the treatment not been intensified? Are the his blood vessels being protected? Are his kidneys being protected? Is his heart being protected? And are his nerves already being damaged by maybe side effect of medications or from missing B12 or from diabetes itself over time? And by the time the wound appeared, the damage had already been building for years. His wound never healed. Six months later, he was gone. So again, something to learn. It's not just a wound in his foot that causes a problem. When you have a problem of non-healing ulcer or of wound in the foot, it also tells us a bigger picture that it's the blood vessels are involved, so it's a heart that is involved as well. So treating one thing at a time does not take the whole picture in account. We got to treat the person as a whole. And, you know, as I have mentioned about another patient in the past where she had type 2 diabetes, diagnosed for a long time, which was misdiagnosed LADA or autoimmune disease, where she needed insulin. So things like that makes you think that why did nobody offer her the care that she needed? And you can look at it as by the time they come to me as an endocrinologist, they're already 10 years past, and the patient has been to two or three different primary cares. So yeah, no one is looking at the picture as a whole.

SPEAKER_00 7:16

And it sounds like the system wasn't really protecting them. I think you've mentioned this previously, in these scenarios, no one was really the quarterback. And that kind of stuck with me because I think that is such a powerful way to say it. Because you can have the best players on the field, the cardiologist, the kidney doctor, the diabetes specialist, the primary care doctor. But if no one is really calling the plates, then the team can still really lose.

SPEAKER_01 7:38

And Leila, so true. And most patients do not even know that there is supposed to be a quarterback. You know, they assume someone is coordinating, they assume the doctors are talking to each other, and they assume the system is watching the whole picture, but too often it is not. And that is why the patients need a framework, and not because their doctor is not good, but because the system is not so flawless that they can depend on it. And that system that I'm offering in the book or the framework that I'm offering in the book can help them understand how they can self-advocate for themselves and how they can work with their doctors and how they can expect the care that they deserve.

SPEAKER_00 8:19

And I think that with all of that being said, the distinction really matters because not your own doctor, your own quarterback. So how does a patient really go about closing this gap? Because they can't really recognize the healthcare system from their living room, right? So what can they do?

SPEAKER_01 8:35

Yeah, they cannot close the gap themselves, but they can do two very important things. First is they can ask one question who's coordinating my care across all my conditions? You know, even then you got to have your primary care doctor or your endocrinologist make sure they understand what the cardiologist is doing, what the nephrologist is doing, and there's a complete picture. And naming the gap is a first step of closing it. You know, if the patient knows where the problem is, then they can address. That means having one place where the key numbers live and are being discussed with the patient, your A1C, your blood glucose, your blood pressure, your cholesterol, your kidney function, your weight, things that matter, you know, your medications, your targets, where should it be? It means knowing not only your diagnosis, but also your goals. You know, where do you expect it to be? What should your numbers be when you wake up? What should your numbers be when you go to bed? It means walking into every appointment with a very clear picture of where you stand. Because even if your doctors are not connecting the dots, you can begin to do that. And that is why I created the diabetes compass in my book. The diabetes compass connects all six gaps into one integrated plan, one person, one body, one plan, one direction. And the summit or the goal is to take least number of medications, to take the least number of doses that we can with excellent diabetes control and with protection of the heart and the kidneys and the brain. And that's what I call as lower the dose. But that is not anti-medication. That is just a way to say that let's not do polypharmacy, let's not keep adding medications by every specialist that you're seeing, but keeping it to the bare minimum, which is very important and optimizing those. So the diabetes compass is what the system should be giving patients, but too often it is not. And the book teaches you how to build it yourself.

SPEAKER_00 10:34

Absolutely. And I think that what you mentioned that this book really teaches you how to build for yourself and really how to advocate for yourself. So really teaches you how, like we mentioned, to become your own quarterback, not necessarily your own doctor, but really be that advocate for yourself. And I think that that's such a powerful lesson and really, really important for patients to know for sure. And you said something earlier that I liked as well, as much as a simple question about who is coordinating my care. Question as simple as that to really gain clarity is I think very, very valuable for sure, especially hearing it from the provider. I think that really will change the way that patients think about that. So let us put the six gaps together clearly, because I do want every listener to really walk away with something practical. Six gaps, six questions, six things that you can bring to your next doctor's appointment. So starting off with one, the diagnosis gap. Are you sure it is type two? The remission gap. Where am I on the timeline? And is the window to remission still open? The protection gap. Am I on one of those organ protective medications? Should I be? The monitoring gap. Can I try a continuous glucose monitor? The education gap. Has someone referred me to diabetes education and the system gap? So who is coordinating my care across all of my conditions, which is a key takeaway, which we mentioned earlier. And these six questions, you don't need a medical degree to ask them, you don't need permission. You just need to really bring them into the room. And Dr. Rangi, I kind of want to go back to the two patients that you described earlier, the man who unfortunately lost his leg and the woman who had a stroke. So if they had known about these six gaps, what do you think might have been different in these scenarios?

SPEAKER_01 12:09

Yes, Leila, if someone had questioned that man's treatment plan earlier, his story may be completely different. If his care had been intensified when his blood sugars first went above the goal or when he was running high all these years, instead of allowing his A1C to remain dangerously high for nearly a decade, his story may have been very different. If someone had asked whether his heart, kidneys, nerves, blood vessels were being protected, if someone had started the right medications earlier, if someone had been coordinating the whole picture, he might still be walking beside his son today, not leaning on the walker, not recovering from an amputation, and walking with his own two legs. And the woman who had stroke, if someone had questioned the diagnosis earlier, her story may have been completely different. If someone had asked, are we sure we are treating type 2 diabetes? Even if the patient is not interested in injections, is there an alternative? Do we have an option or do we need to look into what is the best treatment for her diagnosis? And a simple test like an antibody test that can be done on a blood work may have recognized its years sooner. You know, if she had been started on the right treatment, the right support around the fear of using needles, using the tools like inhaled insulin or insulin pump or technology, her blood sugar could have been controlled for years instead of remaining dangerously high for again, you know, eight to ten years. So that stroke may have never happened. And that is unfortunately the tragedy. I see that every day in my practice. A lot of people have these complications from diabetes that could have been totally prevented. These are not futuristic treatments. These exist at this time, and these are not experimental tests, and these are not impossible questions. They exist, but they were not used. They were not ordered, they were not asked, and that is what this book is trying to change. You know, we're trying to empower the patients to understand what the journey looks like if you have diabetes or prediabetes and what to expect over time and what are the right questions to ask your doctors so that you can be empowered.

SPEAKER_00 14:24

Absolutely. And you have a line in the book that I really want to close with because I think it was such a powerful statement. The rest requires a movement, but these six require only you. So what did you mean by that?

SPEAKER_01 14:35

Yeah, I'm glad you brought that up, Leila. When I looked through the system, because I was frustrated from seeing so many complications over the years, I noticed that it's not surprising. Many different organizations and regulatory organizations have documented this clearly that there are at least 50 gaps in care. Many of them require governments, medical societies, health systems, insurance companies, institutions, you know, policymakers to fix it. And they should fix them. But these six gaps are different. And as I had mentioned them earlier as well, these are the six gaps that I chose because they have enough evidence, you get exponential benefit if you address them. They benefit on the patient care or outcomes multiplies. And number three, the patients can follow them easily. Because of that, I picked up these six. These six do not require you to wait for Congress, these do not require for you to wait for committee, and they do not require you to wait for healthcare system to redesign itself. These six require your knowledge, your voice, your questions, your willingness to walk into an exam room and say, please show me the plan, please show me my timeline. Where am I on? Can I reverse my pre-diabetes if I'm still in that I call as last exit in my book? If you have early diabetes, you can go into remission. Am I still at a place where I can live without medications and do everything I can to not get dependent on medications and preserve my beta cells? Or if I'm late in the disease, what can we do to protect my organs? You know, show me the options. Show me how my heart, my kidneys, my nerve, eyes, future are being protected. You know, that is not being difficult. That is being informed. You know, that is being proactive. I would love that kind of a patient who's just asking me to be self-advocating for himself. That is understanding that your future is being shaped right now.

SPEAKER_00 16:37

Absolutely. And if you are listening to this and you do have diabetes or you love someone who does, I definitely want you to do three things. So, first, write down these six questions, put them in your phone, bring them to your next appointment, and make sure that you review these with your provider. And second, read the book. This is the structured education that so many patients never receive. And third, make sure that you share this episode with one person who needs to hear it. Because the education gap does not close by itself. It closes when we stop waiting for the system to educate us and really start educating each other. And I think that this book is so helpful for so many reasons, specifically that. And I know that this will definitely help so many patients, Dr. Angi.

SPEAKER_01 17:16

Yeah, Leila, I wrote this book because I do not want to sit across from another patient and know that what happened to them was preventable. You know, this book is in my way of reaching the people I may never meet in my office, but who deserve the same answers. They deserve to know their type, they deserve to know their timeline, they deserve to know their if remission is still possible, they deserve to know whether their organs are protected, and they deserve access to monitoring education and a coordinated plan. They deserve better than a fragmented care. They deserve a blueprint, and that's what I've created.

SPEAKER_00 17:56

Absolutely. And those patients deserve better, and so do you. So thank you so much, Dr. Rangi, for writing this book and really helping with this education gap. And don't forget to those listeners who do have an appointment coming up, make sure that you take these six questions with you, bring them to your next appointment, share them with someone you love because the future of diabetes care cannot live only in research papers and guidelines. It has to reach the patient, and the patient may be you. Or if it's not you, someone you love. So make sure you're also following, subscribing, and sharing the show. And Dr. Rangi, can you remind us when your book will be out for the listeners who want to definitely get a copy of it?

SPEAKER_01 18:31

Yeah, Leila, we expect the book to come out on August 12th if everything goes well, because sometimes that's not in my hand. But if they go and sign up for updates, they can definitely find that. It's rangemd.com slash blueprint, and they can sign up so they can get the updates on when the book is coming out. One more thing, Leila. I just want to repeat the six questions again so the people who have not had a chance to write those can understand it clearly. Number one, the diagnosis gap where people can be misdiagnosed as type two. So make sure you ask your doctor, are you sure I have type two diabetes? Number two is remission gap. Try to understand where you are in the disease state. If you are early, then there's a possibility you may go into remission by changing your lifestyle and you may not need to be on medication. The way we define remission is not to be on medication for three months and under excellent control. Then the third is a protection gap. Then you have to ask your doctors, am I on those organ protective medications? Am I taking any medication that'll protect my heart, my brain, my kidneys? And if I'm not, then should I be on? Right? So there are some cases where patient may not be the right candidate because of certain situations. So ask that question. Then the next question is monitoring gap. So do ask, can I try continuous glucose monitor if you're not on one? Now there is some problem there with insurance companies not covering and whatnot, but I would highly educate and encourage patients to request for a prescription for a continuous glucose monitor and try that at least for 15 days or two weeks, even if your insurance doesn't cover, because that will tell you immense information about your lifestyle and it can guide you what things really shoot up your blood sugars, how can you change how you eat, move, sleep, and you know, everyday activity. And then there are two more things that they need to ask. One is, did I ever get diabetes education, complete diabetes education? If not, then ask your doctor to refer to someone and read my book, The Diabetes Blueprint. And then the last one is System Gap, where we talk about fragmented care and not a coordinated care. So be your own advocate and make sure you ask yourself and your doctor who's keeping an eye on all the all of my care and the specialists that I'm seeing. And am I meeting all the goals and the targets where I deserve to be and should be on?

SPEAKER_00 20:50

Absolutely. Thank you so much for again writing this book and sharing this information with all of our listeners. And make sure that you do take those six questions with you and you read the book. And it was always a pleasure speaking with you. I can't wait for our next episode. We're getting closer to your book launch, so I know that's super exciting. And again, everyone listening, make sure you're following and subscribing the show. And we'll see you next time. Sounds good, Leila. Thank you so much.