Navigating the road to diabetes

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The growing number of people along the road to diabetes – from the early, or “pre-diabetes” stage, to those living with the disease, to those with complications and ultimately, those who succumb to the disease – is increasingly alarming. Health professionals play a crucial role in helping guide patients along this continuum, and have the unique opportunity to lead by example. The ultimate goal is to get individuals off the road to diabetes – with aggressive screening and management at all stages.

Growing concernThe numbers are sobering: an estimated 45 million Canadians and Americans have pre-diabetes. Without intervention, the majority of these individuals will progress to diabetes within 10 years. In Canada, the prevalence of diabetes is estimated to be greater than seven per cent of the population. This means that 2.2 million Canadians have type 2 diabetes. An aging population, rising rates of obesity, declining rates of physical activity, and increasing immigration from high-risk populations are all expected to contribute to a higher prevalence of diabetes in Canada by 2025.

We are already seeing evidence of this higher prevalence: a report by the Institute for Clinical Evaluative Sciences and published earlier this year in The Lancet showed that, as of 2005, diagnosis rates in Ontario had already exceeded the global rate predicted by the World Health Organization for 2030. The study’s author stated that, if current trends continue, 10 per cent of Ontario’s adult population will be diagnosed with diabetes by 2010.The longer a person has diabetes, the greater their risk of complications and death – according to the Canadian Diabetes Association, (CDA), on average, patients with diabetes are 15 years closer to a heart attack, stroke, or death from any cause. There is a significant impact in hospitals: for instance, people with diabetes make up about one-third of all hospital admissions for heart attack, and hospitalization rates for stroke were nearly three times higher for patients with diabetes.

The good news is that we now have effective “exit” strategies to prevent patients from going down this dangerous route to diabetes and its associated complications. Implementing exit strategies – using early screening principles and published evidence as a guide – along the disease continuum is an important common goal for health professionals.

Exit strategies: managing pre-diabetes and diabetes Pre-diabetes occurs in those who have blood glucose levels that are higher than normal, but are not high enough to be classified as diabetes. In patients with pre-diabetes, even a moderate increase in postprandial, or post-meal, plasma glucose levels has been shown to be an independent risk factor for cardiovascular disease. Clinical evidence continues to point to elevations in postprandial glucose as an early marker for diabetes. That’s why early screening is so essential. The CDA recommends that everyone over the age of 40 be screened every three years. In addition, those with additional risk factors – such as being overweight, having heart disease, having a first-degree relative with diabetes, or being from a high-risk population, such as those of Aboriginal, Hispanic, Asian, South Asian, or African descent – should be considered for more frequent testing, or earlier routine screening. And health professionals should not think themselves immune – those with these risk factors should consider screening.

A number of clinical studies have shown that lifestyle and medical intervention can slow the progressive nature of type 2 diabetes by contributing to blood sugar control. In addition, recent clinical studies have demonstrated that a class of oral anti-diabetic medications known as thiazolidinediones (TZDs) improved glycemic control in individuals with pre-diabetes or diabetes. Currently there are no oral anti-diabetic medications indicated for pre-diabetes.

Achieving and maintaining glucose control to recommended targets through these kinds of interventions is key. One study, called the DICE (Diabetes in Canada Evaluation) study, evaluated diabetes care in the family practice setting and highlighted that one in two Canadian patients with diabetes is poorly-controlled and is not being managed to target (i.e. HbAIC > 7%). The study also concluded that current management practices are not aggressive enough to prevent complications, hence the need for more aggressive therapy.

The bottom line Aggressive screening and management at all phases of the diabetes continuum provides the direction needed to appropriately navigate the road to diabetes. Looking ahead, results from ongoing clinical trials are expected to provide additional data in support of intensified screening and more aggressive management of pre-diabetes and diabetes.