West-German German Diabetes Centre 2 diabetes mellitus has. grown dramatically around the world. Diabetes is the fifth-leading cause. of death by disease in …
COMPREHENSIVE MANAGEMENT OF TYPE 2 DIABETES Prof Dr Stephan Martin Medical Director West-German German Diabetes Centre During the past years world wide the numbers of persons affected by type 2 diabetes mellitus has grown dramatically around the world Diabetes is the fifth-leading cause of death by disease in the US and also contributes to higher rates of morbidity DEVELOPMENT OF COMPLICATIONS AND COSTS Microvascular complications as blindness or chronic kidney failure appears several years after diabetes diagnosis, however the time to vascular events as myocardial infarction stroke is substantially shorter This was recently shown in the German multicentre, retrospective cohort study ROSSO, that observed a representative cohort of 3142 newly diagnosed type 2 diabetes patients with a public health-insurance plan from randomly contacted 192 GP practices At diagnosis of type 2 diabetes previous diagnosis of myocardial infarction MI was present in 4 and stroke in 32 of the patients During follow up over 7 years the complication rate rose linearly to 73 for MI and 86 for stroke, while other diabetic endpoints as haemodialysis 14amputation 12 and blindness 06 rose but-stayed lower Total
cost of diabetes care was 1288 for the first treatment year with diagnosed diabetes and amounted to 3845 in-the year seven Even in the first years after diagnosis 58 of the cost was spent for the treatment of complications and this proportion increased to 83 in the seventh year Average costs per patient and year were 3210 ; while 6 was spent for medication and only less than 3 for monitoring systems
LIFESTYLE MODIFICATION: HEN AND EGG Type 2 diabetes is related to the western lifestyle Next to dietary factors the la;k of physical activity leads to insulin resistance, obesity and consecutively to blood glucose disorders Even large prevention studies have shown that the incidence of diabetes can be reduced by lifestyle intervention, its therapeutically, potential after onset of diabetes is underestimated In a subgroup of the Malmo Preventive Study it was shown that 50 of persons with diagnosis of type 2 diabetes and subsequent lifestyle modification were in complete remission 5 years later The major challenge is to convince patients to modify behavior since blood glucose elevations are without symptoms_ Therefore, it is important to visualize the metabolic risk by self-monitoring
of blood glucose Sfv18G before and 1,5–2 hours after meals In addition so-called Event Driven SMGB addition gives patients the chance to analyze the influence of different food or physical activity in the metabolic control SMBG also effects the long term outcome in type 2 diabetes as it has been shoe in the ROSSO study which was described before During the mean follow up of 65 years 453 began with SMBG prior to an endpoint, including 32 of patients not receiving insulin The total rate of non-fatal events such as myocardial infarction, stroke, amputation, heamodyalisis, or blindness, was lower in the SMBG group 72 vs 104 p0002 A similar difference was found for the rate of fatal events 27 vs 46, p004 The same better outcome was also observed in the SMBG cohort when only patients not receiving insulin were analyzed Co medication for lowering blood pressure, Lipids or for thrombocyte aggregation inhibition was not more aggressive in the SMGB cohort ROSSO also documents that SMGB is a cost effective way of achieving a better metabolic control
resulting in less complications The additional monitoring costs are insignificant relative to the savings The lower frequency of SMBG among
subjects pauing higher out-of-pocket expenditures for strips suggests that removal of financial barriers by providing more comprehensive coverage for these costs may optimize the management of diabetes In conclusion, non pharmaceutical interventions have a high therapeutically potential to prevent and treat type 2 diabetes and its devastating complications
Paper
Comprehensive Management of Type 2 Diabetes Prof Dr Stephan Martin Medical Director of the West-German German Diabetes Centre, Hospital of the State Capital Düsseldorf Grulinger Str 120 40625 Düsseldorf During the past years world wide dramatic changes in lifestyle have occurred Automation of the working processes, computer use in working and leisure time in addition to overfeeding have affected the human health more dramatically than expected These are the causes for lifestyle diseases as diabetes mellitus type 2, hypertension or hyperlipidaemia The numbers of persons affected by type 2 diabetes mellitus has grown dramatically around the world Due to the fact that these lifestyle diseases are strongly associated and represent cardiovascular risk factors, diabetes is the fifth leading cause of death by disease in the US
Microvascular complications as blindness or chronic kidney failure appear several years after diabetes diagnosis, however the time to vascular events as myocardial infarction or stroke is substantially shorter This was recently shown in the German multicentre, retrospective
cohort study ROSSO, that observed a representative cohort of 3142 newly diagnosed type 2 diabetes patients with a public health insurance plan from randomly contacted 192 GP practices At diagnosis of type 2 diabetes previous diagnosis of myocardial infarction MI was present in 4 and stroke in 32 of the patients During follow up over 7 years the complication rate rose linearly to 73 for MI and 86 for stroke, while other diabetic endpoints as haemodialysis 14, amputation 12 and blindness 06 rose but stayed lower Total cost of diabetes care was 1288 for the first treatment year with diagnosed diabetes and amounted to 3845 in the year seven Even in the first years after diagnosis 58 of the cost was spent for the treatment of complications and this proportion increased to 83 in the seventh year Average costs per patient and year were 3210 , while 6 were spend for medication and only less than 3 for monitoring
systems
As described above type 2 diabetes is related to the western lifestyle Next to dietary factors the lack of physical activity leads to insulin resistance, obesity and consecutively to blood glucose disorders Even large prevention studies have shown that the incidence of diabetes can be reduced by lifestyle intervention, its therapeutically potential after onset of diabetes is underestimated In a subgroup of the Malm Preventive Study it was shown that 50 of persons with diagnosis of type 2 diabetes and subsequent lifestyle modification were in complete remission 6 years later Even the number of oral antidiabetic drugs are increasing and different insulin formulations are available, the basal therapy for type 2 diabetes must be a lifestyle modification This is the biggest challenge for health care systems worldwide Lifestyle modification has the lowest rate of side effects, nevertheless it is not easy to convince the patients Therefore new strategies as motivation programs for a higher rate of physical activity and better food are needed Self-monitoring of blood glucose SMBG is one very effective method for persons with type 2 diabetes to monitor their lifestyle SMBG also
affects long-term outcome in type 2 diabetes as it has been shown recently in the ROSSO study This epidemiological multicentre, retrospective cohort study was performed by us using the data of people with type 2 diabetes in unperturbed routine practice in Germany A total of 3268 patients were followed from diagnosis of type 2 diabetes between 1995 and 1999 until the end of 2003 for diabetes-related morbidity nonfatal myocardial infarction, stroke, foot amputation, blindness, haemodialysis or all-cause mortality During the mean follow-up of 65 years 453 began with SMBG prior to an endpoint,
including 32 of patients not receiving insulin The total rate of nonfatal events, as myocardial infarction, stroke, amputation, haemodialysis of blindness, was lower in the SMBG than in the non-SMBG group 72 vs 104, p0002 A similar difference was found for the rate of fatal events 27 vs 46, p0004 After statistical adjustments for baseline characteristics of patients and physicians the results in the SMBG group were still significant lower in comparison to the group without the use of SMBG The same better outcome was also observed in the SMBG cohort when only patients not receiving insulin were
analysed When patients were synchronized to the start of SMBG a marked reduction of metabolic control was noted Co medication for lowering blood pressure, lipids or for thrombocyte aggregation inhibition was not more aggressive in the SMGB cohort ROSSO also documents that SMBG is a cost-effective way of achieving a better metabolic control resulting in less complications The additional monitoring costs are insignificant relative to the savings The lower frequency of SMBG among subjects paying higher out-ofpocket expenditures for strips suggests that removal of financial barriers by providing more comprehensive coverage for these costs may optimize the management of diabetes
The results have affected the guidelines of the International Diabetes Federation IDF recently published These guidelines demand SMBG as standard care for all newly diagnosed people with type 2 diabetes as an integral part of selfmanagement education How often and at which time points SMBG should be used to convince patients to modify behavior? We have suggested that in a first step patients should visualize the metabolic risk by measuring blood glucose before and 15-2 hours after meals Thereafter they should
document the values in view of the normal values In addition so called event driven SMBG gives patients the chance to analyze the influence of different food or physical activity to the metabolic control In conclusion non pharmacological interventions have a high therapeutically potential to prevent and treat type 2 diabetes and its devastating complications
Source:teamiha.org
