European Journal of General Practice
ISSN: 1381-4788 (Print) 1751-1402 (Online) Journal homepage: http://www.tandfonline.com/loi/igen20
Diabetes mellitus—a global pandemicKeynote lecture presented at the Wonca conference in Prague in June 2013 Jan Škrha To cite this article: Jan Škrha (2014) Diabetes mellitus—a global pandemicKeynote lecture presented at the Wonca conference in Prague in June 2013, European Journal of General Practice, 20:1, 65-68 To link to this article: http://dx.doi.org/10.3109/13814788.2013.847083
Published online: 19 Dec 2013.
Submit your article to this journal
Article views: 66
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=igen20 Download by: [University of Prince Edward Island]
Date: 05 November 2015, At: 14:04
European Journal of General Practice, 2014; 20: 65–68
Background Paper
Diabetes mellitus—a global pandemic Keynote lecture presented at the Wonca conference in Prague in June 2013
Downloaded by [University of Prince Edward Island] at 14:04 05 November 2015
Jan Škrha 3rd Department of Internal Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
KEY MESSAGE: • A significant number of people with diabetes remain undiagnosed. • Early screening of persons with risk factors associated with diabetes or prediabetes is necessary. • Prevention of diabetes cannot be implemented by physicians alone without the involvement of governments, industry and the active participation of individuals engaging in a healthy lifestyle.
ABSTRACT The huge increase in the number of people with diabetes mellitus over recent decades raises questions about early diagnosis, intensive treatment and primary prevention. Insulin and oral agents’ discoveries have improved the prognosis of patients with diabetes, but vascular complications still remain the main cause of increased morbidity and mortality. Therefore, strategies oriented to the prevention of diabetes and its complications are the main goal in the care of diabetic patients. Further intensive efforts will be necessary not only by the community of physicians and scientists, but also governments, industry, non-governmental organizations and by individuals engaging in a healthier lifestyle. Better diabetes awareness and lifestyle changes may significantly reduce the main problems with diabetes. Keywords: diabetes mellitus, early diagnosis, effective treatment, prevention, vascular complications
INTRODUCTION Non-communicable diseases occupy a dominant position in general morbidity both in developed and developing countries. The clinical interest of physicians and scientists is rising because the number of people with this group of diseases steadily increases. Diabetes mellitus is one of the most important examples fulfilling the criteria of epidemic disease. The last edition of the Atlas of International Diabetes Federation (IDF) describes the actual number of patients with diabetes comprising 366 million in 2011 with a forecast of about 550 million in 2030 (1). This alarming development has created tasks not only for physicians but also for politicians, the business community and the general population as well.
This article is based on a keynote lecture presented at the Wonca conference in Prague in June 2013. It reflects the present role of diabetes in medical care. The increasing clinical significance of diabetes creates the need to evaluate past and present achievements in diagnosis and treatment and to outline some goals for future development. In addition, the reader will recognize the need for better prevention of diabetes and challenges for the future.
ACHIEVEMENTS OF THE PAST In the past, patients with diabetes mellitus lacking insulin synthesis in B-cells died without substitution
Correspondence: Jan Škrha, 3rd Department of Internal Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic. E-mail: [email protected] (Received 4 June 2013; accepted 21 August 2013) ISSN 1381-4788 print/ISSN 1751-1402 online © 2014 Informa Healthcare DOI: 10.3109/13814788.2013.847083
Downloaded by [University of Prince Edward Island] at 14:04 05 November 2015
66
J. Škrha
by exogenous insulin. The discovery of the key role of the pancreas in the glucose homeostasis in 1921 (2) initiated a new development in diabetes treatment. Insulin was introduced in clinical practice in 1922. It saved the lives of millions of patients in subsequent decades because its everyday application and a regular daily regimen were recommended to patients with diabetes. However, the insulin substitution was inappropriate because the patients´ first experience with hypoglycaemia induced them to reduce their insulin doses. In addition, short acting insulin was substituted by longer acting insulin administered once or twice daily. Since the 1930s, long-term insufficiently controlled diabetes has been associated with retinopathy, neuropathy and nephropathy. Diabetic patients had higher morbidity and died earlier than nondiabetics. Insulin treatment has created many questions for physicians and scientists since the beginning. Some diabetic patients had to be treated with insulin once the diagnosis was established (insulin-dependent diabetes, IDDM) while for others, insulin could be administered later after several years of oral agent treatments (noninsulin-dependent diabetes, NIDDM). Both groups were distinguished mainly by clinical experience. Different aetiologies, either autoimmune (Type 1 diabetes corresponding to IDDM) or metabolic (Type 2 diabetes corresponding to the vast majority of NIDDM), have been in use since the 1980s (3). Sulphonylureas and biguanides coming into the market in 1957–58 (4,5) have improved diabetes control for a substantial portion of Type 2 diabetic patients. However, no evidence was available for the question if long-term administration of insulin or oral agents could reduce chronic vascular complications like retinopathy, nephropathy, neuropathy and/or cardiovascular disease or stroke. The idea of a link between treatment strategies and both metabolic control and chronic complications initiated the first clinical studies. Long-term follow up of diabetic patients in the United Kingdom Prospective Diabetes Study (UKPDS) and Diabetes Control and Complications Trial (DCCT) confirmed the relationship between diabetes control and chronic vascular complications (6,7). Hence, better and long-term diabetes control from the diagnosis of diabetes could reduce development of microvascular complications. Lower target values for plasma glucose and glycated haemoglobin (HbA1c) concentrations have been suggested in the treatment of diabetic patients, reducing the development of chronic complications (8). The ‘evidence based’ results of multicentre clinical trials have been used in recommendations of management of Type 2 diabetes mellitus (9). However, the UKPDS and DCCT studies and later trials like ACCORD or VADT showed that tight control was associated with higher frequency of hypoglycaemic episodes (10,11). The harmful effect of
hypoglycaemia has been repeatedly demonstrated mainly in older patients with cardiovascular disease. The difference in age, sex or presence of other diseases showed that treatment strategies have to be individually implemented (12). Target values of laboratory variables should be considered with proper knowledge of the respective patient, whereas generalization in the treatment targets for every patient would be a mistake.
CURRENT STATE OF THE ART Diabetes mellitus is not only the impairment of plasma glucose concentration alone but in addition with multiple metabolic effects, it is the most frequent cause of the vascular wall disorder. The early stage of diabetes called prediabetes is characterized by slightly increased plasma glucose concentration in the presence of impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). The diabetes epidemic has expanded across the world, despite growing knowledge of its prevention and intensive care. Diabetes, like non-communicable diseases, is different when compared to infections representing communicable diseases, which have been successfully eradicated in some countries. Diabetes care is now based on the recommendations (13), but new language for communication of health professionals with diabetic patients have been suggested to provide more effective care (14). Diagnosis of diabetes is rather late if clinical symptoms would be already present. However, in a considerable number of other persons corresponding to 25–50% of patients with known diabetes, the disease remains undiscovered. Glycated haemoglobin along with plasma glucose could be used for diagnosis worldwide if the standardization of the HbA1c measurement is performed (15). While the genetic background is different in Type 1 and Type 2 diabetes and exact data on all candidate genes in Type 2 diabetes are missing, the B-cell failure is the common cause in development of both types of diabetes (16). In daily practice, genes are not used to confirm the diagnosis of diabetes. Modern guidelines summarize the current trends in diagnosis and treatment of diabetes (15). Successful treatment consists of four pillars: physical activity, dietary regimen, mental status and drugs. All of them influence diabetes control and consequently good education or counselling provided by a diabetes care team may improve the patient´s motivation for treatment procedures. Deficient physical activity and higher caloric intake are the most frequent sources of poor glucose control, which may be only partly counterbalanced by intensified drug treatment. Modern guidelines offer a different combination of oral agents and/or insulin for Type 2 diabetes (13). However, glucose control remains far from physiological regulation despite more intensive
Downloaded by [University of Prince Edward Island] at 14:04 05 November 2015
Diabetes mellitus—a global pandemic treatment. In addition, more fluctuation between hypoglycaemia and hyperglycaemia may be observed. While blood pressure or plasma lipids can be successfully treated to target values in diabetic patients, it is difficult to do it in case of the plasma glucose concentration. Better results in diabetes control may be obtained by complex care for individual diabetic patients (17), but it is not the case in many patients at the present time. Usually, diabetes control progressively worsens with duration of diabetes. The treatment intensity depends on the physician´s recognition of individual diabetic patient. The patients of younger age, with short duration of diabetes and no additional vascular diseases may be treated more intensively, whereas fragile older patients with a longer history of diabetes and cardiovascular disease need special attention to prevent hypoglycaemic episodes. They should remain on less strict glucose control and thus with higher values of glycated haemoglobin (18). General practitioners (GP) or family doctors (FD) play a key role in the diagnosis and treatment of the vast majority of diabetic patients in many countries. Apparently, collaboration of GP’s or FD’s with diabetologists/ endocrinologists and other specialists improves current diabetes care and prognosis of patients.
CHALLENGES FOR THE FUTURE The increasing number of patients with diabetes poses questions not only for physicians. An undertaking for the future is the implementation of effective prevention of diabetes, which is currently the cause of various global health problems. Non-modifiable (genetic) factors will not be changeable in the foreseeable future, although lifestyle modifications involving appropriate daily physical activity and a healthy and reliable food intake can be put in place at present to prevent diabetes, arterial hypertension, dyslipidaemia, obesity and other risks. The present forms of information in newspapers, TV and other media have a very limited effect. The active participation of governments and policy makers with concrete plans must play a greater role in the prevention of non-communicable diseases in the future instead of the current situation at present. A public health strategy will have to coordinate the needs of a healthy lifestyle in the general population starting from childhood. The families and schools may have to have a major role in lifestyle modification. The prevention of diabetes will be an arduous path, but without concrete steps the epidemic of diabetes will continue (19). There is a role for everybody to take, whereas physicians themselves might have limited possibilities to influence development in the future. Diagnosis of diabetes is frequently too late. Type 2 diabetes is confirmed usually after several years of duration when the glucose concentration is permanently
67
increased. It initiates changes in the vascular wall, much earlier than the diagnosis could be established. Plasma glucose lowering to normal concentrations just after the diagnosis of diabetes cannot immediately stop the process of changes in tissues, especially in the vascular wall. This is due to the phenomenon called ‘glucose memory’ causing sustained activation of vascular cells by previously increased glucose concentration (20). Early detection of diabetes and prediabetes by primary care physicians will be one of the main issues in future screening programmes. It will reduce the number of patients with undiagnosed impaired glucose metabolism. Once diagnosed, diabetes has to be intensively treated to reach the glucose control close to normal values. In addition, a complex treatment involving tight control of other risk factors like arterial hypertension, dyslipidaemia or body weight can significantly reduce vascular wall impairment (21). It is only through an intensive treatment strategy can the development of complications be delayed or attenuated. Physiological regulation can be restored by transplantation of the islets of Langerhans possessing the integrity of endocrine cells. However, future research will be needed to solve the problems of appropriate insulin substitution, perhaps with the use innovative technology. The closed loop system using insulin pumps is on the way, although it does not solve the entire complexity of the disease. It will improve insulin sensitivity in peripheral tissues while an inappropriate amount of insulin itself may worsen its action in patients using insulin syringes or pens. New treatment strategies, including medications, influencing some of the pathogenic mechanisms of the B-cell destruction (scavenger/anti-oxidant enzymes, blockers of activated immune reactions including cytokines, etc.) could be developed in the future. More intensive cooperation of general practitioners or family doctors with diabetologists or endocrinologists as well as other members of the diabetes care team will be extremely important from the beginning of treatment. Patient education by the diabetes care team will strengthen their motivation to a healthy lifestyle, which will further improve the effects of drug treatment. In conclusion, the diabetes epidemic needs special attention of the public and not just physicians or other members of the diabetes care teams. It is the real global health problem for the future, and it requires the initiation of a healthy lifestyle straightaway in childhood. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper. REFERENCES 1. IDF Diabetes Atlas. Fifth edition, 2011. 2. Bliss MJJR. MacLeod and the discovery or insulin. QJ Exp Physiol 1989;74:87–96.
Downloaded by [University of Prince Edward Island] at 14:04 05 November 2015
68
J. Škrha
3. Balkau B, Eschwege E. The diagnosis and classification of diabetes and impaired glucose regulation. In: Pickup JC, Williams G, editors. Textbook of diabetes, 3rd ed. Oxford: Blackwell Science; 2003. pp. 2.1–2.10. 4. Stern J. Blood-sugar lowering effect of 1,1-dimethylbiguanide. Therapie 1958;13:650–9. 5. Loubatiers A. The hypoglycemic sulphonamides: History and development of the problem from 1942 to 1955. Ann New York Acad Sci. 1957;71:4–11. 6. Shamoon H, Duffy H, Fleischer N, Engel S, Saenger P, Strelzyn M, et al. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complication in insulindependent diabetes mellitus. N Engl J Med. 1993;329:977–86. 7. Turner RC, Holman RR, Cull CA, Stratton IM, Matthews DR, Frighi V, et al. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837–53. 8. Ryden L, Standl E, Bartnik M, den Berghe G, Bettridge J, de Boer MJ, et al. The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD) Guidelines on diabetes, pre-diabetes, and cardiovascular diseases. Europ Heart J. 2007;28:88–136. 9. Nathan DM, Buse JB, Davidson MB, Ferrannini E, Holman RR, Sherwin R, et al. Management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy. Diabetologia 2009;52:17–30. 10. Bonds DE, Miller ME, Bergenstal RM, Buse JB, Byington RP, Cutler JA, et al. The association between symptomatic severe hypoglycaemia and mortality in type 2 diabetes: Retrospective epidemiological analysis of the ACCORD study. Br Med J. 2010;340:b4909.
11. Patel A, MacMahon S, Chalmers J, Neal B, Billot L, Woodward M, et al. Intensive blood glucose control and vascular outcomes in patients with Type 2 diabetes. N Engl J Med. 2008;358:2560–72. 12. Del Prato S, La Salle J, Matthaei S, Bailey CJ. Tailoring treatment to the individual in type 2 diabetes practical guidance for the global partnership for effective diabetes management. Int J Clin Practice 2010;64:295–304. 13. Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, et al. Management of hyperglycaemia in type 2 diabetes: A patient-centered approach. position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2012;55:1577–96. 14. Speight J, Conn J, Dunning T, Skinner TC, on behalf of Diabetes Australia. Diabetes Australia position statement. A new language for diabetes: Improving communications with and about people with diabetes. Diab Res Clin Pract. 2012;97:425–31. 15. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care 2013;36:S11–S66. 16. Gurzov EN, Eizirik DL. Bcl-2 proteins in diabetes: Mitochondrial pathways of β-cell death and dysfunction. Trends Cell Biol. 2011;21:424–31. 17. Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med. 2008;358:580–91. 18. Huelgas RG, Diez-Espino J, Formiga F, Tejedor JL, Manas RL, Gonzales-Sarmiento E, et al. Treatment of type 2 diabetes in the elderly. Med Clin. 2013;140:134. 19. Shin JA, Lee JH, Kim HS, Choi YH, Cho JH, Yoon KH. Prevention of diabetes: A strategic approach for individual patients. Diabetes Metabol Res Rev. 2012;28(Suppl. 2):79–84. 20. Ceriello A. The emerging challenge in diabetes: The ‘metabolic memory’. VasculPharmacol. 2012;57:133–8. 21. Sattar N. Revisiting the links between glycaemia, diabetes and cardiovascular disease. Diabetologia 2013;56:686–95.
ISSN: 1381-4788 (Print) 1751-1402 (Online) Journal homepage: http://www.tandfonline.com/loi/igen20
Diabetes mellitus—a global pandemicKeynote lecture presented at the Wonca conference in Prague in June 2013 Jan Škrha To cite this article: Jan Škrha (2014) Diabetes mellitus—a global pandemicKeynote lecture presented at the Wonca conference in Prague in June 2013, European Journal of General Practice, 20:1, 65-68 To link to this article: http://dx.doi.org/10.3109/13814788.2013.847083
Published online: 19 Dec 2013.
Submit your article to this journal
Article views: 66
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=igen20 Download by: [University of Prince Edward Island]
Date: 05 November 2015, At: 14:04
European Journal of General Practice, 2014; 20: 65–68
Background Paper
Diabetes mellitus—a global pandemic Keynote lecture presented at the Wonca conference in Prague in June 2013
Downloaded by [University of Prince Edward Island] at 14:04 05 November 2015
Jan Škrha 3rd Department of Internal Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
KEY MESSAGE: • A significant number of people with diabetes remain undiagnosed. • Early screening of persons with risk factors associated with diabetes or prediabetes is necessary. • Prevention of diabetes cannot be implemented by physicians alone without the involvement of governments, industry and the active participation of individuals engaging in a healthy lifestyle.
ABSTRACT The huge increase in the number of people with diabetes mellitus over recent decades raises questions about early diagnosis, intensive treatment and primary prevention. Insulin and oral agents’ discoveries have improved the prognosis of patients with diabetes, but vascular complications still remain the main cause of increased morbidity and mortality. Therefore, strategies oriented to the prevention of diabetes and its complications are the main goal in the care of diabetic patients. Further intensive efforts will be necessary not only by the community of physicians and scientists, but also governments, industry, non-governmental organizations and by individuals engaging in a healthier lifestyle. Better diabetes awareness and lifestyle changes may significantly reduce the main problems with diabetes. Keywords: diabetes mellitus, early diagnosis, effective treatment, prevention, vascular complications
INTRODUCTION Non-communicable diseases occupy a dominant position in general morbidity both in developed and developing countries. The clinical interest of physicians and scientists is rising because the number of people with this group of diseases steadily increases. Diabetes mellitus is one of the most important examples fulfilling the criteria of epidemic disease. The last edition of the Atlas of International Diabetes Federation (IDF) describes the actual number of patients with diabetes comprising 366 million in 2011 with a forecast of about 550 million in 2030 (1). This alarming development has created tasks not only for physicians but also for politicians, the business community and the general population as well.
This article is based on a keynote lecture presented at the Wonca conference in Prague in June 2013. It reflects the present role of diabetes in medical care. The increasing clinical significance of diabetes creates the need to evaluate past and present achievements in diagnosis and treatment and to outline some goals for future development. In addition, the reader will recognize the need for better prevention of diabetes and challenges for the future.
ACHIEVEMENTS OF THE PAST In the past, patients with diabetes mellitus lacking insulin synthesis in B-cells died without substitution
Correspondence: Jan Škrha, 3rd Department of Internal Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic. E-mail: [email protected] (Received 4 June 2013; accepted 21 August 2013) ISSN 1381-4788 print/ISSN 1751-1402 online © 2014 Informa Healthcare DOI: 10.3109/13814788.2013.847083
Downloaded by [University of Prince Edward Island] at 14:04 05 November 2015
66
J. Škrha
by exogenous insulin. The discovery of the key role of the pancreas in the glucose homeostasis in 1921 (2) initiated a new development in diabetes treatment. Insulin was introduced in clinical practice in 1922. It saved the lives of millions of patients in subsequent decades because its everyday application and a regular daily regimen were recommended to patients with diabetes. However, the insulin substitution was inappropriate because the patients´ first experience with hypoglycaemia induced them to reduce their insulin doses. In addition, short acting insulin was substituted by longer acting insulin administered once or twice daily. Since the 1930s, long-term insufficiently controlled diabetes has been associated with retinopathy, neuropathy and nephropathy. Diabetic patients had higher morbidity and died earlier than nondiabetics. Insulin treatment has created many questions for physicians and scientists since the beginning. Some diabetic patients had to be treated with insulin once the diagnosis was established (insulin-dependent diabetes, IDDM) while for others, insulin could be administered later after several years of oral agent treatments (noninsulin-dependent diabetes, NIDDM). Both groups were distinguished mainly by clinical experience. Different aetiologies, either autoimmune (Type 1 diabetes corresponding to IDDM) or metabolic (Type 2 diabetes corresponding to the vast majority of NIDDM), have been in use since the 1980s (3). Sulphonylureas and biguanides coming into the market in 1957–58 (4,5) have improved diabetes control for a substantial portion of Type 2 diabetic patients. However, no evidence was available for the question if long-term administration of insulin or oral agents could reduce chronic vascular complications like retinopathy, nephropathy, neuropathy and/or cardiovascular disease or stroke. The idea of a link between treatment strategies and both metabolic control and chronic complications initiated the first clinical studies. Long-term follow up of diabetic patients in the United Kingdom Prospective Diabetes Study (UKPDS) and Diabetes Control and Complications Trial (DCCT) confirmed the relationship between diabetes control and chronic vascular complications (6,7). Hence, better and long-term diabetes control from the diagnosis of diabetes could reduce development of microvascular complications. Lower target values for plasma glucose and glycated haemoglobin (HbA1c) concentrations have been suggested in the treatment of diabetic patients, reducing the development of chronic complications (8). The ‘evidence based’ results of multicentre clinical trials have been used in recommendations of management of Type 2 diabetes mellitus (9). However, the UKPDS and DCCT studies and later trials like ACCORD or VADT showed that tight control was associated with higher frequency of hypoglycaemic episodes (10,11). The harmful effect of
hypoglycaemia has been repeatedly demonstrated mainly in older patients with cardiovascular disease. The difference in age, sex or presence of other diseases showed that treatment strategies have to be individually implemented (12). Target values of laboratory variables should be considered with proper knowledge of the respective patient, whereas generalization in the treatment targets for every patient would be a mistake.
CURRENT STATE OF THE ART Diabetes mellitus is not only the impairment of plasma glucose concentration alone but in addition with multiple metabolic effects, it is the most frequent cause of the vascular wall disorder. The early stage of diabetes called prediabetes is characterized by slightly increased plasma glucose concentration in the presence of impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). The diabetes epidemic has expanded across the world, despite growing knowledge of its prevention and intensive care. Diabetes, like non-communicable diseases, is different when compared to infections representing communicable diseases, which have been successfully eradicated in some countries. Diabetes care is now based on the recommendations (13), but new language for communication of health professionals with diabetic patients have been suggested to provide more effective care (14). Diagnosis of diabetes is rather late if clinical symptoms would be already present. However, in a considerable number of other persons corresponding to 25–50% of patients with known diabetes, the disease remains undiscovered. Glycated haemoglobin along with plasma glucose could be used for diagnosis worldwide if the standardization of the HbA1c measurement is performed (15). While the genetic background is different in Type 1 and Type 2 diabetes and exact data on all candidate genes in Type 2 diabetes are missing, the B-cell failure is the common cause in development of both types of diabetes (16). In daily practice, genes are not used to confirm the diagnosis of diabetes. Modern guidelines summarize the current trends in diagnosis and treatment of diabetes (15). Successful treatment consists of four pillars: physical activity, dietary regimen, mental status and drugs. All of them influence diabetes control and consequently good education or counselling provided by a diabetes care team may improve the patient´s motivation for treatment procedures. Deficient physical activity and higher caloric intake are the most frequent sources of poor glucose control, which may be only partly counterbalanced by intensified drug treatment. Modern guidelines offer a different combination of oral agents and/or insulin for Type 2 diabetes (13). However, glucose control remains far from physiological regulation despite more intensive
Downloaded by [University of Prince Edward Island] at 14:04 05 November 2015
Diabetes mellitus—a global pandemic treatment. In addition, more fluctuation between hypoglycaemia and hyperglycaemia may be observed. While blood pressure or plasma lipids can be successfully treated to target values in diabetic patients, it is difficult to do it in case of the plasma glucose concentration. Better results in diabetes control may be obtained by complex care for individual diabetic patients (17), but it is not the case in many patients at the present time. Usually, diabetes control progressively worsens with duration of diabetes. The treatment intensity depends on the physician´s recognition of individual diabetic patient. The patients of younger age, with short duration of diabetes and no additional vascular diseases may be treated more intensively, whereas fragile older patients with a longer history of diabetes and cardiovascular disease need special attention to prevent hypoglycaemic episodes. They should remain on less strict glucose control and thus with higher values of glycated haemoglobin (18). General practitioners (GP) or family doctors (FD) play a key role in the diagnosis and treatment of the vast majority of diabetic patients in many countries. Apparently, collaboration of GP’s or FD’s with diabetologists/ endocrinologists and other specialists improves current diabetes care and prognosis of patients.
CHALLENGES FOR THE FUTURE The increasing number of patients with diabetes poses questions not only for physicians. An undertaking for the future is the implementation of effective prevention of diabetes, which is currently the cause of various global health problems. Non-modifiable (genetic) factors will not be changeable in the foreseeable future, although lifestyle modifications involving appropriate daily physical activity and a healthy and reliable food intake can be put in place at present to prevent diabetes, arterial hypertension, dyslipidaemia, obesity and other risks. The present forms of information in newspapers, TV and other media have a very limited effect. The active participation of governments and policy makers with concrete plans must play a greater role in the prevention of non-communicable diseases in the future instead of the current situation at present. A public health strategy will have to coordinate the needs of a healthy lifestyle in the general population starting from childhood. The families and schools may have to have a major role in lifestyle modification. The prevention of diabetes will be an arduous path, but without concrete steps the epidemic of diabetes will continue (19). There is a role for everybody to take, whereas physicians themselves might have limited possibilities to influence development in the future. Diagnosis of diabetes is frequently too late. Type 2 diabetes is confirmed usually after several years of duration when the glucose concentration is permanently
67
increased. It initiates changes in the vascular wall, much earlier than the diagnosis could be established. Plasma glucose lowering to normal concentrations just after the diagnosis of diabetes cannot immediately stop the process of changes in tissues, especially in the vascular wall. This is due to the phenomenon called ‘glucose memory’ causing sustained activation of vascular cells by previously increased glucose concentration (20). Early detection of diabetes and prediabetes by primary care physicians will be one of the main issues in future screening programmes. It will reduce the number of patients with undiagnosed impaired glucose metabolism. Once diagnosed, diabetes has to be intensively treated to reach the glucose control close to normal values. In addition, a complex treatment involving tight control of other risk factors like arterial hypertension, dyslipidaemia or body weight can significantly reduce vascular wall impairment (21). It is only through an intensive treatment strategy can the development of complications be delayed or attenuated. Physiological regulation can be restored by transplantation of the islets of Langerhans possessing the integrity of endocrine cells. However, future research will be needed to solve the problems of appropriate insulin substitution, perhaps with the use innovative technology. The closed loop system using insulin pumps is on the way, although it does not solve the entire complexity of the disease. It will improve insulin sensitivity in peripheral tissues while an inappropriate amount of insulin itself may worsen its action in patients using insulin syringes or pens. New treatment strategies, including medications, influencing some of the pathogenic mechanisms of the B-cell destruction (scavenger/anti-oxidant enzymes, blockers of activated immune reactions including cytokines, etc.) could be developed in the future. More intensive cooperation of general practitioners or family doctors with diabetologists or endocrinologists as well as other members of the diabetes care team will be extremely important from the beginning of treatment. Patient education by the diabetes care team will strengthen their motivation to a healthy lifestyle, which will further improve the effects of drug treatment. In conclusion, the diabetes epidemic needs special attention of the public and not just physicians or other members of the diabetes care teams. It is the real global health problem for the future, and it requires the initiation of a healthy lifestyle straightaway in childhood. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper. REFERENCES 1. IDF Diabetes Atlas. Fifth edition, 2011. 2. Bliss MJJR. MacLeod and the discovery or insulin. QJ Exp Physiol 1989;74:87–96.
Downloaded by [University of Prince Edward Island] at 14:04 05 November 2015
68
J. Škrha
3. Balkau B, Eschwege E. The diagnosis and classification of diabetes and impaired glucose regulation. In: Pickup JC, Williams G, editors. Textbook of diabetes, 3rd ed. Oxford: Blackwell Science; 2003. pp. 2.1–2.10. 4. Stern J. Blood-sugar lowering effect of 1,1-dimethylbiguanide. Therapie 1958;13:650–9. 5. Loubatiers A. The hypoglycemic sulphonamides: History and development of the problem from 1942 to 1955. Ann New York Acad Sci. 1957;71:4–11. 6. Shamoon H, Duffy H, Fleischer N, Engel S, Saenger P, Strelzyn M, et al. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complication in insulindependent diabetes mellitus. N Engl J Med. 1993;329:977–86. 7. Turner RC, Holman RR, Cull CA, Stratton IM, Matthews DR, Frighi V, et al. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837–53. 8. Ryden L, Standl E, Bartnik M, den Berghe G, Bettridge J, de Boer MJ, et al. The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD) Guidelines on diabetes, pre-diabetes, and cardiovascular diseases. Europ Heart J. 2007;28:88–136. 9. Nathan DM, Buse JB, Davidson MB, Ferrannini E, Holman RR, Sherwin R, et al. Management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy. Diabetologia 2009;52:17–30. 10. Bonds DE, Miller ME, Bergenstal RM, Buse JB, Byington RP, Cutler JA, et al. The association between symptomatic severe hypoglycaemia and mortality in type 2 diabetes: Retrospective epidemiological analysis of the ACCORD study. Br Med J. 2010;340:b4909.
11. Patel A, MacMahon S, Chalmers J, Neal B, Billot L, Woodward M, et al. Intensive blood glucose control and vascular outcomes in patients with Type 2 diabetes. N Engl J Med. 2008;358:2560–72. 12. Del Prato S, La Salle J, Matthaei S, Bailey CJ. Tailoring treatment to the individual in type 2 diabetes practical guidance for the global partnership for effective diabetes management. Int J Clin Practice 2010;64:295–304. 13. Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, et al. Management of hyperglycaemia in type 2 diabetes: A patient-centered approach. position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2012;55:1577–96. 14. Speight J, Conn J, Dunning T, Skinner TC, on behalf of Diabetes Australia. Diabetes Australia position statement. A new language for diabetes: Improving communications with and about people with diabetes. Diab Res Clin Pract. 2012;97:425–31. 15. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care 2013;36:S11–S66. 16. Gurzov EN, Eizirik DL. Bcl-2 proteins in diabetes: Mitochondrial pathways of β-cell death and dysfunction. Trends Cell Biol. 2011;21:424–31. 17. Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med. 2008;358:580–91. 18. Huelgas RG, Diez-Espino J, Formiga F, Tejedor JL, Manas RL, Gonzales-Sarmiento E, et al. Treatment of type 2 diabetes in the elderly. Med Clin. 2013;140:134. 19. Shin JA, Lee JH, Kim HS, Choi YH, Cho JH, Yoon KH. Prevention of diabetes: A strategic approach for individual patients. Diabetes Metabol Res Rev. 2012;28(Suppl. 2):79–84. 20. Ceriello A. The emerging challenge in diabetes: The ‘metabolic memory’. VasculPharmacol. 2012;57:133–8. 21. Sattar N. Revisiting the links between glycaemia, diabetes and cardiovascular disease. Diabetologia 2013;56:686–95.
