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Treatment Trends for Type 2 Diabetes

The burden of diabetes is expected to increase over the next few decades in the United States, with about one in three American adults projected to be at risk for developing the disease by 2050. Diabetes has also been linked to a considerable economic burden, with annual direct medical expenditures for treating and managing the disease totaling nearly $250 billion in 2012. Most of the medical expenditures for diabetes are attributable to hospitalizations and physician services, but the costs of prescription therapies are also significant. With the high prevalence and burden of diabetes, the disease has become a ripe target for pharmaceutical development. “During the past decade, several important changes in the diabetes marketplace have occurred,” explains G. Caleb Alexander, MD, FACP. For example, in the early 2000s, glitazones were rapidly adopted for use, but subsequent evidence suggested that these agents were associated with cardiovascular risks. In turn, this led to substantial declines in the use of glitazones during the latter half of the decade.  In addition, new long-acting insulins and several new classes of therapies have emerged to treat type 2 diabetes, including injectable incretin mimetics such as glucagon-like peptide 1 (GLP-1) agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, and sodium glucose cotransporter 2 (SGLT-2) inhibitors. The costs of these medications can be high, but clinicians appear to be interested in using them because of their novel mechanisms of action and potential promise in helping to improve glycemic control among those with type 2 diabetes.   Examining Recent Patterns Over the past 2 decades, clinical investigations have examined changes in the treatment of diabetes. These analyses identified several important trends,...
Treating Type 2 Diabetes in Youths

Treating Type 2 Diabetes in Youths

The American Diabetes Association recently released nutrition therapy recommendations for the management of diabetes. Published in Diabetes Care, the new statement provides a set of recommendations based on reviews of recent clinical investigations (Table 1). The statement calls for all adults diagnosed with diabetes to eat a variety of nutrient-dense foods in appropriately portioned sizes as part of an eating plan. These plans must take into account individual preferences, culture, religious beliefs, traditions, and metabolic goals. Nutrition Therapy Is Effective The American Diabetes Association recognizes that nutrition therapy is provided by a variety of health professionals, and published research shows that it is effective when delivered by various health professionals. Studies suggest that nutrition therapy produces A1C reductions similar or greater than what is expected with treatment with currently available pharmacologic treatments for diabetes. “Ideally, patients with diabetes should be referred to registered dietitians (RDs) for diabetes nutrition therapy or participate in diabetes self-management education (DSME) programs that include instruction on nutrition soon after their diagnosis,” says Alison Evert, MS, RD, CDE, who was part of the writing group that developed the position statement. The position statement from the American Diabetes Association highlights guidelines from the Academy of Nutrition and Dietetics that recommend several effective structural components when implementing medical nutrition therapy for adults with diabetes (Table 2). “An important goal of nutrition therapy includes collaborating with healthcare providers to develop individualized eating plans and to encourage people with diabetes to get the ongoing support they need to promote health behavior changes.” Individualizing Approaches The American Diabetes Association recommends that all people with diabetes make nutrition therapy a part...
Diabetics & Ethnic Minorities: Going Beyond Black & White

Diabetics & Ethnic Minorities: Going Beyond Black & White

According to 2010 United States Census data, the number of Asians and Pacific Islanders (APIs) in the country has risen 43% since 2000. The three largest API subgroups included people of Chinese, South Asian, or Filipino ancestry. A recent report from the U.S. National Health Interview Survey aggregated API subgroups and found substantive differences in diabetes prevalence. “Unfortunately, there is still a paucity of published data on diabetes in API subgroups in the U.S.,” says Maria Rosario Araneta, PhD. “APIs have been a population group that has largely been neglected in diabetes research.” New Insights on Ethnic Differences in Diabetes In 2013, researchers in the Diabetes Study of Northern California (DISTANCE) had an analysis published in Diabetes Care that estimated racial and ethnic differences in the prevalence and incidence of the disease. The DISTANCE study involved a large, multi-ethnic cohort of patients receiving care in an integrated health delivery system. It included more than 2 million adult members of Kaiser Permanente Northern California. According to findings, there was considerable variation among the seven largest API subgroups. Pacific Islanders, South Asians, and Filipinos had the highest prevalence (18.3%, 15.9%, and 16.1%, respectively) of diabetes. These groups also had the highest incidence (19.9, 17.2, and 14.7 cases per 1,000 person-years, respectively) of diabetes among all racial and ethnic groups, including minorities who are traditionally considered high risk, such as African Americans, Latinos, and Native Americans (Figure). “Findings from this study are consistent with previous research, but there was substantial variation across the API subgroups,” adds Dr. Araneta. The Role of BMI at Diabetes Diagnosis Another key finding from the DISTANCE study...
Enhancing Diabetes Knowledge in Patients

Enhancing Diabetes Knowledge in Patients

The National Diabetes Education Program (NDEP) was established, in part, to improve treatment and outcomes for people with diabetes by increasing knowledge of A1C, blood pressure (BP), and LDL cholesterol; together, these components make up the “ABCs” of diabetes. Few studies, however, have explored patient knowledge of their ABC levels and the association between having this knowledge and adhering to treatment recommendations for each of the ABC components. ABC Diabetes Knowledge From Patients Still Lacking In Diabetes Care, my colleagues and I had a study published in which we sought to assess patient knowledge of ABC levels and the association between this knowledge and meeting the ABC target goals. We also evaluated the association between specific demographic and diabetes-related factors and ABC knowledge. The purpose was to see if these data could help physicians and researchers identify high-risk patients who had particularly low knowledge.   According to our findings, knowledge of the ABCs was suboptimal. Among patients with diabetes, our data showed that: 48% could report their last A1C level. 63% could report their BP level. 22% could report their last LDL level. Knowledge was lower among Mexican Americans when compared with non-Hispanic whites and in people with less income and education. Having routine foot exams performed by physicians in the past year was associated with higher A1C knowledge. Nearly 20% of study participants reported that their healthcare provider did not specify an A1C goal. About three of every five participants reported that they were not informed of their BP or LDL cholesterol goals (47% and 41%, respectively). Significant Implications on Controlling Diabetes Physician communication of the ABC goals...
Gastric Bypass Surgery for Mild Obesity in Diabetics

Gastric Bypass Surgery for Mild Obesity in Diabetics

In 2003, a study of more than 1,000 patients who underwent gastric bypass found that one-third of those with diabetes at baseline had normal blood sugars after their surgery and didn’t need medication when they were discharged from their surgical hospitalization. This finding sparked further exploration into the effects of gastric bypass surgery on weight-independent, antidiabetes mechanisms. Testing a New Population In Diabetes Care, my colleagues and I had a study published that explored the use of Roux-en-Y gastric bypass (RYGB) as a primary modality to treat type 2 diabetes in patients for whom weight loss was not the primary objective. When we began the study, clinical observations had suggested that diabetes remits in about 80% of patients who undergo gastric bypass. What we didn’t know was the durability of that effect or what the outcomes would be in patients who weren’t severely obese. In our analysis, we selected 66 consecutive patients with type 2 diabetes who were mildly obese (BMI between 30 kg/m2 and 35 kg/m2) to undergo RYGB. These patients were prospectively studied for up to 6 years. At baseline, they had an average A1C of 9.7% despite being on insulin or at least two diabetes medications. At 6 months after RYGB, the average A1C level decreased to 6.5% and continued to decrease to 6.1% at 6 years, with 100% follow-up in this cohort. At the latest follow-up, 88% of patients had achieved diabetes remission, which was defined as having an A1C of 6.5% or less and being off all diabetes medications. We also found that â-cells were nearly five times more sensitive to blood sugar, on...
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