How to treat type 2 diabetes more effectively for a lower cost? The Court of Auditors answered this complicated but emblematic question in a recent report by proposing that a care path including the therapeutic education of the patient, nutritional intervention and adapted physical activity, is proposed to each patient diagnosed early.
To be egalitarian in this disease that preferentially affects the most disadvantaged, this personalized route should be supported financially. This additional cost could be envisaged as part of an ALD (long -lasting affections) on two levels depending on the severity of the disease. Explanations.
It is chronic disease that most affects the least favored people
Type 2 diabetes: an unequal distribution in the population
In 2023, 3.8 million people were treated for diabetes, the most widespread pathology being, for a very large majority, a type 2 diabetes (92 %). In connection with the increase in obesity and the aging of the population, this form of diabetes has experienced strong growth for several years. However, despite the rapid progression of the prevalence of this pathology, France remains less affected than the other countries, which is, according to data from the International Diabetes Federation, in the fourth row of the least affected countries in the European Union (EU at 27), after Ireland, the Netherlands and Sweden.
Diabetes is a socially unequal pathology, because much more frequent in the most disadvantaged people. The risk of developing this pathology is thus 2.8 times higher for the most modest populations of the population than for the easiest 10 %.
“It is chronic disease that most affects the least favored people,” said the president of the Court of Auditors, Pierre Moscoviciduring the presentation of the report at a press conference. Unsurprisingly, these inequalities overlap those observed in the increase in overweight and obesity, the first risk factor of type 2 diabetes whose prevalence is also unequally distributed in the territory-the overseas departments and regions being particularly affected.
Constant expenses
Another observation of the Court, and this is its field of expertise: the level of health expenses attributable to diabetes is growing, while the quality of management does not know any significant improvement. This is evidenced by the level of health expenditure attributable to diabetes which “progresses correlatively, like that of all the care and benefits of diabetic persons, mainly under the effect of aging and increasing longevity which lead to an increase in the number of patients with diabetes and on the part presenting complications”, write the rapporteurs.
These expenses are estimated by the National Health Insurance Fund (CNAM) at 10.2 billion euros, an increase of 34.8 % since 2015, making it the fourth post of expenses among chronic diseases.
“The health and financial issue is therefore quite substantial,” said the president of the Court of Auditors. While at the same time, the health results do not progress hardly, so we spend much more for results that do not progress or little, he insists.
Type 2 diabetes is emblematic of the urgent need to modify our health system, in an effective prevention logic.
While the risk factors to develop the disease and then its complications are known, as are the care and monitoring recommendations, the indicators for carrying out monitoring and prevention examinations are only slowly progressing. In addition, a sign of a low improvement in the quality of early management of diabetes, the number of hospitalizations for complications decreases little since 2013. In addition, while diabetes can be detected early by identifying risk factors (age, weight, etc.), almost 30 % of people who are newly supported for diabetes in 2021 present an already advanced disease.
The therapeutic modification of lifestyles, the first treatment of diabetes
Therefore, it is necessary to develop an earlier management of the disease. “It is imperative to improve the management, early detection, monitoring diabetes, still well below recommendations as shown in the report,” asserts Pierre Moscovici.
“If multiple initiatives (Sophia remote support service of health insurance, the nursing system of the ASAALE ASSAINTE association, etc.) have developed at the local level to promote the detection of diabetes, they do not have the extent necessary to effectively detect those affected who could usefully benefit from early management allowing a therapeutic modification of lifestyles, first treatment of diabetes,” he said. It would therefore appear more relevant, to guarantee equitable access to therapeutic support, “to offer each patient, when his diabetes is diagnosed, a course or a basket of care integrating therapeutic education and adapted physical activity”.
There would no longer be a single ALD but two slices, one of which would be dedicated to patients with less severe disease.
At an early stage where there is not yet a question of drugs, “non-drug management must be the management of ordinary law” adds the Court of Auditors during the presentation.
Create two ALD levels
To do this, the rapporteurs find it appropriate to reflect on the reimbursement of a care path, as was recommended in June
2024 by the General Inspections of Social Affairs and Finance
(IGAS and IGF) as part of their review of expenses relating to
Long -term affections (ALD). This would implies a overhaul of the
long -term ailment device, for the benefit of management
Accompaniment of therapeutic changes in lifestyles with a decoupling in two levels of recognition in ALD according to the level of severity and complication.
“Clearly, there would no longer be a single ALD but two slices, one of which would be dedicated to patients with less severe disease. We would integrate support, taking into account the healthy lifestyle measures, which is not the case today, and physical activity, through adapted physical activity (APA) “explained the Court of Auditors during the press conference.
Intensify the nutritional quality policy
Finally, in a context where prevention and public health policies, rather than following a pathology approach, now seek to act on global health determinants, it is important to strengthen primary prevention. “In the case of type 2 diabetes, whose obesity is the main risk factor, the promotion of nutritional quality and physical activity constitutes a major lever,” consider the rapporteurs.
To achieve this, the Court deems it necessary to intensify the consumer awareness and information actions, advertising supervision and regulation of food supply, including by further mobilizing “behavioral taxation”.
Several avenues are recommended: intensifying the policy on nutritional information-clearly, extending the use of Nutriscore, whose presence on food is still today more of the volunteering of agro-food players than a legal obligation-but also extending the tax on sugary drinks to other products containing sugar.
Finally, the wise men of rue Cambon advocate to expand the perimeter of the media (television and social networks) subject to the prohibition of advertising of fatty products, sweet or savory, equivalent to the Nutriscore D and E.
Integrate primary prevention issues to public health policy
Finally, with these findings and measures – which could apply to many other chronic pathologies, have pointed out the rapporteurs -, “type 2 diabetes is emblematic of the urgent need to modify our health system, in an effective prevention logic”.
Today, the presence of determinants largely located outside the sanitary sphere-unpleasant food, sedentary lifestyle…. -, requires that public health policy strongly integrates primary prevention issues.
“This is the only option for improving the health of the population, fairly and sustainable over time,” concluded Pierre Moscovici.
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