As you’ve noted, passive treatment (or non-treatment) is standard for T2 in the US – at least, for people who fit the traditional T2 profile (55 or older, overweight/obese and/or family history of diabetes and/or personal history of hypoglycemia), who are diagnosed by GPs they have had for some time. (Note that most GPs do not have extensive knowledge of diabetes or diabetes care.) Those of us who are diagnosed T2 at a younger age, or who have younger doctors, or whose doctors’ lives are touched by diabetes – may be treated more aggressively.
Glucose testing is a big “elephant in the closet” of T2 management. Many insurance companies do not cover testing (or sufficient testing) for T2s, many T2s are not sent to CDEs or given sufficient education about diabetes, and have no idea what the numbers from their meters mean (or what they can do to affect them). This has been recently reported in a number of studies as “testing in T2 only increases anxiety and does nothing to improve BG/A1C” – an extremely dumbed-down analysis, if you start looking at how rarely the test subjects are testing, and that they are not given any education on what to do with the numbers (other than, maybe, to report them to the doctor). The long and short of the story is that, by and large, T2s do not test sufficiently and do not know enough to modify their behavior based on the readings.
In addition, there are five separate classes of oral medication – each of which works differently, and each of which may be preferred or contraindicated depending on the cause of hyperglycemia (and any other medical issues the patient may have). Unfortunately, medical practice regarding T2 diagnosis is not sufficiently developed to insure that general practitioners (and possibly even endos?) routinely test to determine the underlying cause(s) of persistent and/or postprandial hyperglycemia. This, along with insurance companies’ treatment of all of these classes of drugs as interchangeable, results in physicians not prescribing the correct oral antihyperglycemic and the correct type of diet plan for the patient in question.
Finally, insurance companies don’t always cover sufficient follow-up exams for T2 diabetics. ADA standards suggest 3-6 month follow-ups, depending on lab results and level of “control” – and many GPs are either not informed enough, or not proactive enough, to push for greater levels of care. Add to this that insurance companies have no vested interest in the long-term prognosis of any individual patient, since that patient is likely to be insured by a different company (or uninsured) by the time complications take hold.
Here’s where things get a bit tricky: we are each of us upset seeing someone close to us not taking or receiving optimal care for his/her diabetes, and we would like to see them paying closer attention to their health (and better care for their health) – but there is a limit to how far we can push, depending on the available disposable income (above rent/mortgage, taxes, utilities, transportation, insurance, basic food) and the person’s willingness to take an active role in his/her care. We also have to contend with the attitudes of a previous generation – in which patients entrusted their doctors with their care, and believed that the doctor always knew best – and the time pressures of anyone employed in today’s rat-race-you-need-to-be-more-productive-and-are-expendable-if-you-aren’t culture.