The changing shape of type 2 diabetes

Abstract

Context: Type 2 diabetes is primarily a disease that affects late-middle-aged and elderly individuals. Due to increasing affluence, lifestyle changes, and obesity, however, it is also affecting younger age groups. Therefore, treatment recommendations may need to be revised to reflect these changes. Fortunately, various new treatment options, including insulin analogs with more physiologic time-action profiles and drugs that target the incretin system, are now available.

Evidence acquisition: This review was based on a PubMed literature search done in August 2007, using relevant search terms.

Evidence synthesis: Improving diet and increasing physical activity are important therapeutic interventions in diabetes and associated conditions. However, many people find it difficult to maintain lifestyle changes, which is why the American Diabetes Association recommends lifestyle intervention plus metformin following initial diagnosis. Current guidelines recommend a stepwise approach, with additional oral antidiabetic drugs (OADs) being added as the disease progresses. Insulin therapy should be initiated once OADs fail to control hyperglycemia, as there is good evidence that intensive therapy, with strict glycemic targets, can reduce the long-term microvascular complications that are associated with poorly controlled diabetes. In addition, while the evidence is less conclusive, intensive therapy may also improve long-term macrovascular comorbidities.

Conclusions: It is important that patients with diabetes receive the most effective therapy for maintaining glycemic control and that treatment is modified or augmented in those who are not achieving appropriate glycemic goals. Only by maintaining long-term, effective glycemic control can the microvascular and macrovascular comorbidities associated with diabetes be minimized.

Figure 1

The changing epidemiology of type 2 diabetes. Figure adapted from Wild et al, copyright 2004 American Diabetes Association. Republished with permission.

Figure 2

Benefits related to decreasing HbA_1c. Figure adapted from Stratton et al, copyright 2000, reproduced/amended with permission from the BMJ Publishing Group.