According to the National Diabetes Statistics Report released in June 2015, diabetes affects almost 10% of Americans and more than 25% of those over the age of 65. Because of its impact on the cardiovascular system, diabetes is the leading cause of morbidity and mortality.
Diabetes causes a rise in blood pressure, an increase in cholesterol, obesity, kidney failure, stroke, blindness and poor circulation resulting in amputations — not to mention the mental toll it takes on individuals. Financially, this results in expenditures of over 240 billion dollars per year (American Diabetes Association), with an increasing cost to individual patients from out-of-pocket expenditures to increased health premiums. Thus, the need for aggressive management of this disease has made itself evident. Most concerning is the incidence of Type 2 diabetes (90-95% of diabetes diagnoses) and the rapid rise of these diagnoses in young adults.
Because of the link between diabetes and cardiovascular disease (CVD) and recent clinical trial results, the American Heart Association (AHA) and the American Diabetes Association (ADA) recently updated their recommendations for prevention of CVD in adults with type 2 diabetes. The most notable of these updates is the emphasis on reducing obesity rates and improving nutrition, as these are two of the major causes of insulin resistance in Type 2 diabetes. The recommendations acknowledged that the Mediterranean-style diet and bariatric surgery in patients who have failed behavioral treatment might improve glycemic control and overall health.
Recommendations for glucose control continue to be a patient-centered approach with lowering A1c (glycosylated hemoglobin) as the primary focus of medication treatment. Metformin continues as the accepted first choice for glucose control in Type 2 diabetes because it is unlikely to cause weight gain or hypoglycemia and in some small studies may have a CVD benefit. Additional studies are underway, comparing glucose control and CVD reduction between the different classes of anti-diabetic medications.
Finally, the evidence suggests that statin therapy should be the means of cholesterol control for those between the ages of 40 and 75 when uncontrolled by diet. Of course, individual patient tolerance and other diseases must be taken into account. Additionally, blood pressure control remains an area that continues to evolve between intensive reduction (systolic pressure lower than 130 mmHg) versus standard reduction (lower than 140 mmHg). Currently, the recommendations are for standard reduction although newer studies may show that the intensive blood pressure control may lead to lower incidences of CVD.
Diabetes continues to be a difficult disease to manage, especially in light of its effect on the cardiovascular system. These updated guidelines put into perspective some of the latest information and serve as a useful aid for managing patients with diabetes.
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