Charles H. Hennekens, M.D., Dr.P.H., the first Sir Richard Doll professor and senior academic advisor to the dean in the Charles E. Schmidt College of Medicine at Florida Atlantic University; Marc A. Pfeffer, M.D., Dzau professor of medicine at Harvard Medical School; John W. Newcomer, M.D., executive vice dean of FAU's College of Medicine and interim vice president for research at FAU; Paul S. Jellinger, M.D., affiliate professor at the University of Miami Miller School of Medicine; and Alan Garber, M.D., Ph.D., professor of medicine at Baylor, have published a commentary in the American Journal of Managed Care titled "Treatment of Diabetes Mellitus: The Urgent Need for Multifactorial Interventions." These researchers emphasize the critical need for clinicians to aggressively utilize a multi-pronged approach to reducing the risk of complications and premature death from type 2 diabetes mellitus.
"There is an emerging pandemic of type 2 diabetes that is related to the dramatic increase in obesity, fast becoming the leading avoidable cause of death worldwide," said Hennekens. "People with type 2 diabetes have twice the risk for premature death due to complications from kidney failure, stroke, heart failure, and blindness due to retinopathy."
The authors state that intensive glucose control -- a cornerstone of treatment for patients with diabetes -- is necessary, but not sufficient to achieve the maximum benefits in reducing complications and premature death. Clinicians should consider adopting all approaches of proven benefit in screening and managing their patients, which include adjunctive drug therapies to therapeutic lifestyle changes to achieve sustained weight loss, increases in physical activity, lipid, blood pressure and glycemic control.
According to National Center of Health Statistics data from a random sample of the U.S. population aged 20 years and older, 20 percent have metabolic syndrome -- a constellation of high blood pressure, obesity, insulin resistance, and high cholesterol. In those 50 years or older, 40 percent have metabolic syndrome, and their 10-year risk for a first coronary event is 16 to 18 percent.
The authors advise that evidence-based doses of statins, aspirin, ACE inhibitors or ARBs should be prescribed as adjuncts to therapeutic lifestyle changes in the aggressive management of diabetes.
"The adoption of therapeutic lifestyle changes, which include weight loss and increased physical activity would preclude the need for pharmacologic interventions for most people with type 2 diabetes," said Hennekens. "Unfortunately, in the U.S., many patients prefer the prescription of pills to the prescription of a healthier lifestyle."
U.S. adolescents today are already heavier, less physically active, smoke more, and have already developed type 2 diabetes at a higher rate than their parents' generation did in their adolescence. Thus, they may become the first U.S. generation since 1950 to have higher rates of cardiovascular disease than their parents.
From a clinical and public health perspective, the authors also express their concern on the alarming findings regarding the under-treatment of type 2 diabetes in sub-populations in the U.S. such as the mentally ill as well as in many countries worldwide. They provide best practices guidelines for blood pressure and cholesterol screenings, while urging clinicians and policy makers to implement multifactorial interventions.
It is estimated that if present trends in obesity and physical inactivity continue, it is likely that one-third of U.S. adults will have diabetes by 2050.
- Charles H. Hennekens, MD; Marc A. Pfeffer, MD; John W. Newcomer, MD; Paul S. Jellinger, MD, MACE; and Alan Garber, MD, PhD. Treatment of Diabetes Mellitus: The Urgent Need for Multifactorial Interventions. American Journal of Managed Care, May 2014
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