• Diabetes Mellitus
• Hyperglycemia/Hypoglycemia

• Endocrinology
• Diabetes & Metabolic Syndrome
• Diabetes Mellitus
• Hyperglycemia/Hypoglycemia

Among individuals with diabetes, early intensive glycemic control is associated with long-term benefits 10 or more years later (ie, the legacy effect) [Holman RR et al. N Engl J Med 2008]. Despite this knowledge, in the United States, 1 in 5 adults with diabetes has an HbA1C > 8% [Ali MK et al. N Engl J Med 2013], and for 2 in 5, this HbA1C level persists for ≥ 90 days [Lafata JE et al. Diabetes Care 2009]. In the United Kingdom, it can take between 2 and 7 years for these patients to start additional glucose control medications [Khunti K et al. Diabetes Care 2013]. Neda Laiteerapong, MD, MS, University of Chicago, Chicago, Illinois, USA, discussed the clinical implications of the legacy effect and the lag time before additional antihyperglycemic agents are added.

The legacy effect and lag time represent opportunities to attain benefits that accrue in the future. It is an equation that raises the question of how to convince patients to undertake intensive glycemic treatments now for benefits they may not see for 10 years. A major challenge is that the immediate effects are certain, whereas the long-term benefits are not.

Dr. Laiteerapong presented preliminary results from interviews with 43 adult patients she conducted to assess whether information about the legacy effect and lag time would change their willingness to intensify their treatment for diabetes and hypertension. Their mean age was 59.2 years, 63% were women, and 74% were African American. The duration of their type 2 diabetes mellitus (T2DM) was 3.3 years, they were not treated with insulin, and they had hypertension for a mean 10.6 years.

After establishing a baseline likelihood (scale of 1 to 10) of taking one additional medicine (pill or insulin) for their diabetes or hypertension, patients were provided information on the legacy effect (for diabetes, benefits last an additional 10 years; whereas for hypertension, benefits last only while on medication) and lag time (for diabetes, 10 years; and for hypertension, 3 years) and asked if their likelihood of taking additional medicine would increase, decrease, or remain the same. Other covariates included demographics, time-related variables (eg, perceived life expectancy, degree to which they consider the future, and future expectations about diabetes, hypertension, and medication in general), self-efficacy, outcome expectancy, interest in lag time and the legacy effect, and clinical variables (HbA1C, blood pressure, and medication history).

At baseline, 65% of interviewees had a high likelihood (≥ 7 of 10) of taking an additional pill, and 44% had a high likelihood of taking insulin for their diabetes. After receiving the lag time information, 42% said their likelihood of taking one additional pill decreased. After receiving the legacy effect information, 37% said their likelihood of taking one additional pill increased. The change in likelihood of taking insulin was in the same direction but smaller for the legacy effect and lag time (Table 1). With respect to hypertension, 63% of patients had a high likelihood of taking one additional pill at baseline, but a similar number increased or decreased their likelihood after receiving the information (Table 2).

Based on these preliminary results, Dr. Laiteerapong concluded that the long lag time before the benefits from intensive glucose control is achieved may decrease the willingness of patients to start additional medications; however, the legacy effect may increase this willingness. Preventive health and chronic health behaviors are affected by the way patients consider the future. Thus, legacy effect information could be a simple and effective strategy to motivate patients to intensify their treatment to improve glycemic control earlier in the disease course. Further research is needed to understand how to optimally discuss the legacy effect with patients.

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