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Diabetes: A Growing Epidemic
| Article Date: 5/31/2007 |
Physicians Office Resource Article #1
Diabetes: A Growing Epidemic Ð What Can Physicians Do To Help Patients?
Holly Schachner, MD
Medical Director, Pfizer/Exubera
Diabetes has reached epidemic proportions. By 2030, the World Health Organization predicts that diabetes prevalence worldwide will reach 366 million people, and in the United States, nearly 21 million Americans have diabetes. Other startling statistics:
Diabetes is the sixth leading cause of death in the U.S., contributing to more than 213,000 deaths each year, and an estimated U.S. cost burden of $132 billion annually, and can represent up to 15 percent of health care budgets globally.
Diabetes is likely to be underreported as a cause of death. Studies have found that only about 35 percent to 40 percent of deceased persons with diabetes have diabetes listed anywhere on the death certificate and only about 10 percent to 15 percent have it listed as the underlying cause of death.
Diabetes is the leading cause of new cases of blindness among adults and is the leading cause of end-stage renal disease in the U.S.
Adults with diabetes are two to four times more likely to die of heart disease than adults who do not have diabetes.
About 65 percent of deaths among people with diabetes are due to heart disease and stroke. Majority of adults with diabetes have hypertension and mild to severe forms of nervous system damage.
Overall, the risk for death among people with diabetes is about 2 times that of people without diabetes.
Most people with diabetes have type 2 diabetes, which is a progressive disease, and ultimately many may require insulin in order to maintain good glycemic control. Despite the availability of insulin, a proven and effective treatment for diabetes, glycemic levels have continued to deteriorate. Even though many new therapies for diabetes have been introduced over the last decade, approximately two-thirds of people with type 2 diabetes on therapy still do not have their glycemia well controlled, which can lead to devastating microvascular and macrovascular complications.
Much of the morbidity associated with long-term complications of diabetes can be substantially reduced by achieving target glycemic levels as shown by several large landmark studies.
The dramatic results of the Diabetes Control and Complication Trial (DCCT) effectively ended the debate as to whether glycemic control influences the development of diabetes complications for patients with type 1 diabetes. The results of this trial show unequivocally that intensive therapy to lower hemoglobin A1c (HbA1c) levels effectively delays the onset and slows the progression of diabetic retinopathy, diabetic nephropathy and diabetic neuropathy in patients with type 1 diabetes. The benefits of improved glycemic control for cardiovascular disease was not statistically shown until this population of young patients with type 1 diabetes (13-39 years) got older. There was a reduction in the number of CV events experienced in the intensive control arm; however, this did not reach statistically significance until the number of events increased over time as this population grew older. The 10-year follow-up study, Epidemiology of Diabetes Interventions and Complications (EDIC), found that there was a lower rate of macrovascular and microvascular complications in the patients who received intensive insulin treatment earlier from onset.
The U.K. Prospective Diabetes Study (UKPDS) ended the debate that intensive control was only important for patients with type 1 diabetes. The UKPDS showed that high levels of cardiovascular morbidity and mortality associated with the progression of type 2 diabetes could be reduced with sustained disease management to achieve improved glycemic control.
Despite the evidence from large landmark studies and an armamentarium of therapies, achievement of recommended A1c goals has remained elusive. In the past few years, leading diabetes organizations including the American Association of Clinical Endocrinologists (AACE), the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have attempted to guide clinicians with ways to navigate Òthe stormÓ towards glycemic control, and have issued / updated treatment guidelines for care of patients who have or are developing type 2 diabetes. The guidelines emphasize rapid (every 3 months) addition of medications and transition to new regimens, including the addition of insulin, when target glycemic goals are not achieved or sustained through lifestyle intervention - and have also suggested beginning with lifestyle intervention and metformin.
Although leading diabetes organizations emphasize the importance of insulin initiation, which is proven effective in reducing glycemic levels and the risk of complications, health care providers and patients continue to view insulin initiation as Òlast resortÓ and punishment for not taking care of themselves and some patients have delayed insulin use for as many as five years to 10 years. Patient- and physician-related barriers to the adoption of insulin therapy include fear and anxiety about injecting insulin, concerns about side effects, and personal health beliefs in regard to the use of insulin. There is an unmet need for patients and physicians to understand the effectiveness of insulin for attaining and maintained glycemic control as well as an alternative delivery of insulin therapy that provides optimal glycemic control, is well tolerated, and improves patient adherence.
Taking into consideration the various landmark studies that show insulin treatment helps prevent complications, the treatment guidelines from leading diabetes organizations that support the role of insulin in the treatment paradigm and the importance of attainment and maintenance of glycemic goals, why are glycemic levels continuing to rise and patients continue to have uncontrolled glycemic levels despite new non-insulin treatments that have come to market in the past decade? To get a grip on this spiraling epidemic, it is critical that health care providers understand the progressive of diabetes and loss of insulin secretion over the course of diabetes. And, it is important for patients and providers to understand that many treatments may lose their effectiveness over time due to the progressive decline in beta cell secretion of insulin. Thus, it may be important to initiate a discussion about the progressive nature of diabetes and the benefits of insulin with patients early in their disease, so that when they require additional treatment to maintain control, insulin is an option they will consider to help attain and maintain glycemic control.
Diabetes: A Growing Epidemic Ð What Can Physicians Do To Help Patients?
Holly Schachner, MD
Medical Director, Pfizer/Exubera
Diabetes has reached epidemic proportions. By 2030, the World Health Organization predicts that diabetes prevalence worldwide will reach 366 million people, and in the United States, nearly 21 million Americans have diabetes. Other startling statistics:
Diabetes is the sixth leading cause of death in the U.S., contributing to more than 213,000 deaths each year, and an estimated U.S. cost burden of $132 billion annually, and can represent up to 15 percent of health care budgets globally.
Diabetes is likely to be underreported as a cause of death. Studies have found that only about 35 percent to 40 percent of deceased persons with diabetes have diabetes listed anywhere on the death certificate and only about 10 percent to 15 percent have it listed as the underlying cause of death.
Diabetes is the leading cause of new cases of blindness among adults and is the leading cause of end-stage renal disease in the U.S.
Adults with diabetes are two to four times more likely to die of heart disease than adults who do not have diabetes.
About 65 percent of deaths among people with diabetes are due to heart disease and stroke. Majority of adults with diabetes have hypertension and mild to severe forms of nervous system damage.
Overall, the risk for death among people with diabetes is about 2 times that of people without diabetes.
Most people with diabetes have type 2 diabetes, which is a progressive disease, and ultimately many may require insulin in order to maintain good glycemic control. Despite the availability of insulin, a proven and effective treatment for diabetes, glycemic levels have continued to deteriorate. Even though many new therapies for diabetes have been introduced over the last decade, approximately two-thirds of people with type 2 diabetes on therapy still do not have their glycemia well controlled, which can lead to devastating microvascular and macrovascular complications.
Much of the morbidity associated with long-term complications of diabetes can be substantially reduced by achieving target glycemic levels as shown by several large landmark studies.
The dramatic results of the Diabetes Control and Complication Trial (DCCT) effectively ended the debate as to whether glycemic control influences the development of diabetes complications for patients with type 1 diabetes. The results of this trial show unequivocally that intensive therapy to lower hemoglobin A1c (HbA1c) levels effectively delays the onset and slows the progression of diabetic retinopathy, diabetic nephropathy and diabetic neuropathy in patients with type 1 diabetes. The benefits of improved glycemic control for cardiovascular disease was not statistically shown until this population of young patients with type 1 diabetes (13-39 years) got older. There was a reduction in the number of CV events experienced in the intensive control arm; however, this did not reach statistically significance until the number of events increased over time as this population grew older. The 10-year follow-up study, Epidemiology of Diabetes Interventions and Complications (EDIC), found that there was a lower rate of macrovascular and microvascular complications in the patients who received intensive insulin treatment earlier from onset.
The U.K. Prospective Diabetes Study (UKPDS) ended the debate that intensive control was only important for patients with type 1 diabetes. The UKPDS showed that high levels of cardiovascular morbidity and mortality associated with the progression of type 2 diabetes could be reduced with sustained disease management to achieve improved glycemic control.
Despite the evidence from large landmark studies and an armamentarium of therapies, achievement of recommended A1c goals has remained elusive. In the past few years, leading diabetes organizations including the American Association of Clinical Endocrinologists (AACE), the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have attempted to guide clinicians with ways to navigate Òthe stormÓ towards glycemic control, and have issued / updated treatment guidelines for care of patients who have or are developing type 2 diabetes. The guidelines emphasize rapid (every 3 months) addition of medications and transition to new regimens, including the addition of insulin, when target glycemic goals are not achieved or sustained through lifestyle intervention - and have also suggested beginning with lifestyle intervention and metformin.
Although leading diabetes organizations emphasize the importance of insulin initiation, which is proven effective in reducing glycemic levels and the risk of complications, health care providers and patients continue to view insulin initiation as Òlast resortÓ and punishment for not taking care of themselves and some patients have delayed insulin use for as many as five years to 10 years. Patient- and physician-related barriers to the adoption of insulin therapy include fear and anxiety about injecting insulin, concerns about side effects, and personal health beliefs in regard to the use of insulin. There is an unmet need for patients and physicians to understand the effectiveness of insulin for attaining and maintained glycemic control as well as an alternative delivery of insulin therapy that provides optimal glycemic control, is well tolerated, and improves patient adherence.
Taking into consideration the various landmark studies that show insulin treatment helps prevent complications, the treatment guidelines from leading diabetes organizations that support the role of insulin in the treatment paradigm and the importance of attainment and maintenance of glycemic goals, why are glycemic levels continuing to rise and patients continue to have uncontrolled glycemic levels despite new non-insulin treatments that have come to market in the past decade? To get a grip on this spiraling epidemic, it is critical that health care providers understand the progressive of diabetes and loss of insulin secretion over the course of diabetes. And, it is important for patients and providers to understand that many treatments may lose their effectiveness over time due to the progressive decline in beta cell secretion of insulin. Thus, it may be important to initiate a discussion about the progressive nature of diabetes and the benefits of insulin with patients early in their disease, so that when they require additional treatment to maintain control, insulin is an option they will consider to help attain and maintain glycemic control.