United Health Foundation
Commentary Making a Difference in Diabetes Care Richard Kahn, PhD Chief Scientific Medical Officer American Diabetes Association
The prevalence of diabetes continues to increase at an alarming rate, with over one in five Americans 60 years of age and older affected1 When those with diabetes are added to those with impaired glucose tolerance, the combined prevalence of abnormal glucose metabolism is almost 60 of the population above age 60; the prevalence rate in those 2039 is 18, suggesting that even young people are being affected to a significant degree Of course, with diabetes or pre-diabetes also comes a greatly increased rate of diabetes-specific complications and cardiovascular disease CVD What should we be doing about this serious situation? There are two obvious answers First, we must do whatever is possible with our patients to reduce the likelihood of developing pre-diabetes and to delay its natural progression Second, we must treat aggressively those with diabetes to prevent complications from occurring Although I say that these answers are obvious, it does not seem to have truly hit home to healthcare providers or patients Despite all that we
know, and all the therapies available, the problem continues to increase, and those affected are not meeting well-established goals of therapy2 To prevent pre-diabetes or diabetes, we must place greater emphasis on weight loss and exercise in those who are overweight or obese Equally important, we must continually exhort patients of normal weight not to put on pounds For the former, both drug therapy and lifestyle modification have been shown to be effective in delaying the progression to diabetes, but admittedly both approaches are difficult to maintain and their cost-effectiveness may be challenging3 Nonetheless, and at the very least, it is incumbent upon all health professionals to address the subject candidly with patients without embarrassment or hesitation, even though it may be a sensitive topic Being overweight or obesity is a serious disorder, and, like type 2 diabetes itself, involves a genetic component that, along with an unfavorable environment, predisposes one to the disease Indeed, it is our diabesity environment that is causing us ruin High-densityhigh-caloric and very flavorful foods, conveniently packaged, readily accessible at very affordable prices, and
expertly advertised and marketed, are our bane While this is by no means some sinister plot by the food industry, all of us must now confront this major public health problem, and the medical community must rise up in unison and voice concern In addition, those not yet affected must be cautioned continually to pay close attention to any unnecessary weight gain, avoid non-nutritive foods whenever possible, exercise routinely, and to look upon weight gain as they would all serious environmental insults For those overweight or obese, it is likely to be insufficient to simply mention the advantages of weight reduction: referral for dietary counseling or community-based weight reduction programs is usually necessary, and even then maintaining weight loss requires long-term behavioral change and social support Of course, regular physical activity is also important since the essence of weight reduction is to reduce caloric intake relative to caloric expenditure– however that can be accomplished The consequences of being overweight or obese are not limited to diabetes: hypertension, dyslipidemia, and even some malignancies are co-morbid conditions4 This implies that all overweight/obese
patients should be regularly screened for the well-known cardiovascular risk factors: impaired fasting glucose/diabetes, hypertension, and abnormal lipid values5 Since we know these factors tend to cluster in many individuals, it is imperative to test patients for each, and, when present, to treat each risk factor individually and aggressively We do not, and should not, need to diagnose the metabolic syndrome in order to recommend lifestyle modification for any of these problems, and we should use pharmacologic therapy when appropriate5, 6 Those already affected by diabetes also require routine monitoring for other CVD risk factors Diabetes by itself is a major CVD risk factor, which, when combined with others, becomes even more serious and portends a much greater likelihood that CVD events will soon occur Treating elevated blood glucose values alone is insufficient: all such adult patients should be on low dose aspirin if tolerated, and it is equally important to strive for a normotensive blood pressure and LDL cholesterol values below 100 mg/dL
Commentary Summer, 2006
United Health Foundation
Assessing global CVD risk and deciding how aggressively to treat each abnormality is
not intuitively clear To aid healthcare providers in doing this, the American Diabetes Association has developed a very comprehensive and extensively validated tool that can be of enormous help to providers and patients We invite you to try this free calculator ie Diabetes PHD by going to the web-site: wwwdiabetesorg/diabetesphd There will soon be a much faster version that you will be able to download directly to your personal computer But, in the meantime, the PHD offers you a unique approach toward understanding the negative impact of all known CVD risk factors at any level at which they are found, and the positive impact of reducing all modifiable risk factors to any level you wish As Putting evidence into practice: Outpatient management of type 2 diabetes mellitus indicates,7 we have all the necessary tools to treat diabetes appropriately In addition, the American Diabetes Association and the European Association for the Study of Diabetes recently published explicit guidelines and a well-defined algorithm for achieving acceptable blood glucose values with pharmacotherapy8 We recommended that metformin and lifestyle modification be started immediately upon diagnosis If
acceptable hemoglobin A1c A1C levels are not achieved after quickly titrating metformin to its highest dose, then insulin, a sulfonylurea, or a thiazolidinedione should be added The use of three oral drugs, or other classes of drugs, was not felt to be of great value in most patients Of importance was the recommendation that glycemic targets A1C 7 could and should be obtained soon after within three months of initiating therapy or after any change in the therapeutic regimen The paper also presents a detailed algorithm for insulin therapy, since this drug is clearly the most effective for lowering blood glucose values The treatment of diabetes need not be complex or particularly difficult A wide array of drugs and devices is available, and the goals of therapy are supported by a rich evidence base But, like all chronic diseases, diabetes requires the active involvement of the patient and his or her support system It requires behavioral changes in patients that can be difficult to maintain It also requires regular follow-up visits, careful monitoring, and attention to all cardiometabolic risk factors, so that complications do not develop It is, therefore, a team effort, and your
active participation is critical for success References
1 Cowie CC, Rust KF, Byrd-Holt DD, et al Prevalence of diabetes and impaired fasting glucose in adults in the US population: National Health And Nutrition Examination Survey 1999-2002 Diabetes Care 2006;29:1263-8 Resnick HE, Foster GL, Bardsley J, et al Achievement of American Diabetes Association clinical practice recommendations among US adults with diabetes,1999-2002: the National Health and Nutrition Examination Survey Diabetes Care 2006; 29:531-7 Eddy DM, Schlessinger L, Kahn R Clinical outcomes and costeffectiveness of strategies for managing people at high risk for diabetes Ann Intern Med 2005;143:251-64 Eyre H, Kahn R, Robertson RM; American Cancer Society, the American Diabetes Association, and the American Heart Association Collaborative Writing Committee Preventing cancer, cardiovascular disease, and diabetes: a common agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association Diabetes Care 2004; 27:1812-24 5 Eckel RH, Kahn RA, Robertson RM, et al Preventing cardiovascular disease and diabetes: a call to action from the American Diabetes Association and the American
Heart Association Diabetes Care 2006;29:1697-9 Kahn R, Buse J, Ferrannini E, et al; American Diabetes Association; European Association for the Study of Diabetes The metabolic syndrome: time for a critical appraisal: joint statement from the American Diabetes Association and the European Association for the Study of Diabetes Diabetes Care 2005, 28:2289-304 Feit S Putting evidence into practice: Outpatient management of type 2 diabetes mellitus BMJ Publishing Group 2006 Nathan DM, Buse JB, Davidson MB, et al Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes Diabetes Care [in press]
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Commentary
Summer, 2006
Source:healthinaging.org
