Published evidence is the cornerstone for developing and providing the best therapy for people with diabetes. However, the generation of evidence, particularly from large randomized studies of sufficient duration with patient-oriented outcomes, in a field that is complex and rapidly evolving, is difficult. This theme is taken up in the mediative article by Yki-Jarvinen, who discusses the challenges faced by intervention research in diabetes and details potential solutions. The ongoing discovery of new pathophysiological mechanisms in diabetes increasingly provides promise for newer and more targeted therapies. However, acceptance and implementation of new treatments can often be slow and suboptimal, as described by Unger in his history lesson on the triumphs and tragedies of diabetes therapy. These challenges, along with potential strategies for using and integrating emerging and existing knowledge to improve diabetes therapy, are discussed in several of the reviews on anti-hyperglycemic therapy.
This special issue comprises reviews, reports, and original articles that address some of the most topical aspects of present and future therapeutics and management of diabetes. The increasing prevalence of diabetes and the diverse nature of symptoms and pathophysiological abnormalities present in different populations require a variety of therapeutic regimens, from the most basic and non-pharmacological interventions to more aggressive and pharmacologically charged treatments. These are directed at preventing the onset and progression of the disease, positively altering the natural history or improving the quality of life and life expectancy for those with the condition. Lifestyle changes are fundamental and enduring and require intrusive and intensive support from healthcare systems, families, and activists. In this issue, several authors discuss the anticipated impact and potential efficacy of newer strategies for prevention and prediction, as well as a variety of regimens for acute and chronic glycemic control. An equally important element of diabetes management is the implementation and adherence to a variety of cardiovascular, renal, and retinal protective strategies, a theme which is taken up in several of the articles on diabetes management.
Importance of Diabetes Management
The content should avoid repetition and ensure that each sentence is necessary to yield the informative tone and help to enhance text complexity. This recognition of importance has been reinforced in many studies conducted within Western countries and other parts of the world. Although the specific goals of management may vary, the priority for any person with diabetes is to achieve and maintain a desirable quality of life while minimizing the risk of long-term complications. Owing to the progressive nature of the condition, these goals require a comprehensive and integrated approach to care that is best delivered and sustained over several years within the context of a health system, and within the wider social and physical environment of the individual. Although type 1 diabetes is usually diagnosed in childhood, it is not a condition that affects only the young. Similarly, type 2 diabetes is not confined to middle age or later, and is now being diagnosed at increasingly younger ages across all ethnic groups. In both types of diabetes, diagnosis and subsequent management or treatment can cause significant anxiety and concern for the individual. In the early period, the most common worries relate to fears of being a burden to others, feelings of isolation and stigmatization, and concerns about employment. Long-term concerns include the fear of complications and uncertainty about the future. The varying needs of the person with diabetes can also impact on the family, leading to alterations in family roles and routines.
Key Challenges in Diabetes Treatment
The design and implementation of effective regimens for the prevention and treatment of type 2 diabetes by primary care clinicians and their teams are complex tasks. In general, patients with newly diagnosed diabetes have heterogeneous presentations and concurrent health issues. This complexity often appears daunting for both the patient, who must grapple with behavior change, and the provider, who seeks to offer realistic and effective guidance. The provider’s tasks include patient education on diabetes and its complications, dietary and physical activity recommendations, as well as addressing psychosocial and mental health issues, cardiovascular risk factors, and microvascular complications. The delivery of new complex medical regimens intended to prevent or treat diabetes-related complications further challenges the healthcare team and the patient. These factors are interlaced with scarce dedicated time for diabetes care in the context of competing medical issues. The available diabetes care time in primary care has been shown to be the primary predictor of process of care and subsequent patient outcomes. High-quality diabetes care involving extended team-based management led by the primary care physician has been shown to significantly reduce the risk of complications in type 2 diabetes. However, given that high-quality diabetes care adds at least 1-2 visits worth of primary care practitioner time per week, it is doubtful whether this can be sustained. The current global shift of diabetes care from acute care settings to community-based primary care necessitates health policy changes and dedicated funding to increase the capacity of community-based primary care to deliver high-quality diabetes care.
Strategies for Effective Diabetes Management
In people with type 1 diabetes, adjusted insulin regimens are currently the most flexible and effective way of improving metabolic control. The gold standard is multiple daily injections of insulin with differing types and doses at each meal, guided by an agreed algorithm based on blood glucose monitoring and matched to appropriate dietary intake and exercise. This may in the future be replaced by continuous subcutaneous insulin infusion, but the technology behind this expensive option has until now restricted its availability on healthcare funding. Beta-cell replacement therapy has already been described as a specific way of curing type 1 diabetes, but it is still a matter of debate as to the best timing of this intervention in preventing future complications. It may be appropriate to do this shortly after diagnosis, as relentless glycaemic control for several years after diagnosis of metabolic changes has shown a significant reduction in the prevalence of complications, and some of these patients may have histologically normal kidneys and retinas at the time of transplantation. This therapy is only logical at a time when the prevention of autoimmunity is no longer seen as science fiction and the risks of long-term immunosuppression are justified by possible improvements in quality and quantity of life for patients with type 1 diabetes.
The evaluation of therapeutic regimens is complex, since it varies from patient to patient and the link between dietary regimes, exercise, weight reduction, and compliance to drug therapy on an individual basis might take several months to assess. Therefore, in assessing the impact of therapy on both short-term and long-term glycaemia, it is essential that both patients and health professionals have the tools to fill the gap between counting to monitor daily events and reviewing overall control at future clinic visits. The main objectives of self-monitoring are to educate the patient on lifestyle and medication changes that are necessary to keep blood glucose levels within an acceptable range and to provide information that will motivate the patient and reinforce appropriate therapy changes. Although the main focus of monitoring for all patients is glycaemia, it is now widely accepted that assessment of cardiovascular risk is an essential goal in the management of patients with type 2 diabetes. This factor is particularly significant in assessing the risks and potential benefits of differing drug interventions. Beta-carotene therapy affects lipid profiles in type 2 diabetes, but the cost-benefit in terms of cardiovascular risk has been questioned. And lastly, for patients involving drug therapy, monitoring is essential in assessing whether various drugs are successful in preventing or delaying the onset of diabetes-related complications, as this is an important factor in their differing effects on life expectancy.
Conclusion
This article has discussed the management of diabetes. It has explored the significant potential benefits and the obstacles that prevent optimal management from being achieved. Provision of evidence-based self-management programs and implementation of care pathways with the integration of a multidisciplinary team have shown to be effective at standardizing care and improving patient outcomes. However, the implementation of such initiatives has been patchy. The chronic care model advocates a shift from the traditional acute medical model with the use of decision support, clinical information systems, and a prepared proactive team to promote patient self-management and improve clinical outcomes. If this can be achieved, there is real potential to limit the devastating complications that diabetes can bring. However, the financial burden of implementing these initiatives can be off-putting.
In countries with limited resources, national diabetes programs that focus on providing essential medication and increasing public awareness may be a more realistic goal. Campaigns like the Diabetes India thin on diabetes have shown to be effective in highlighting the burden of diabetes and may start to bring about some of the changes required to combat this illness.