Medical Case Reports

Biography

Biography: Zachary Bloomgarden

Abstract

Projections: Diabetes is increasing. Number of people with diabetes has more than doubled over the past 2 to 3 decades. One driving factor is obesity. In parallel with the increase in obesity has been the aging of the population. There are progressively fewer younger and older persons, and by the year 2100, the numbers of persons 65 years of age and older, 45 to 64 years, and below 20 years will be roughly equal. Because the fastest growth in the occurrence of diabetes has occurred in older persons, who currently have a prevalence of diabetes of 20% to 25% in most countries, this less well-recognized cause of the increase in the number of people with diabetes is of great concern and will further the burden of diabetes complications. Issues: It is widely recognized that the likelihood of myocardial infarction, stroke, lower-extremity amputation, end stage renal disease, and a variety of other micro-macro vascular conditions are more common in individuals with diabetes than in those without diabetes. The relative increase in these conditions attributed to diabetes has declined, leading some to the optimistic position that we may be better addressing diabetes and its complications. Furthermore, advances in treatment that have led to reduction in rates of myocardial infarction and amputation may or may not reduce the healthcare burden for individuals at risk, given the increasingly costly therapeutic approaches required for people with advanced disease. Large cardio-vascular safety trials carried out over the past decade have led many to the opinion that intensive glycemic control is not of benefit in reducing macro vascular risk. The recent report on the 23-year follow up of participants in the Da Qing study, showing a striking 41% reduction in cardiovascular mortality in those who had undergone lifestyle intervention for pre diabetes, certainly suggests that we should not abandon our efforts in the younger, healthier persons with diabetes for whom clinical judgment impels us to continue to endeavor to improve control. Future directions: It has become commonplace to proclaim that what we know derives from our standing on the shoulders of giants, and no discussion of the future of diabetes can overlook the contribution of Kelly West, the epidemiologist who pointed out nearly 40 years ago that “a preventive and a cure are already at hand for most diabetes. The cause is usually obesity; the preventive, and often the cure, is leanness”. How, though, can we reverse the environmental influences of high-calorie foods contributing to the growth in diabetes? It is increasingly apparent that the paradigm of acute care-based medical practice with infrequent visits to providers prescribing medications is of only incomplete relevance to the management of diabetes, which requires a set of lifestyle interventions combined with measures to promote adherence. Novel interventions using technologies such as smartphone apps to improve communication and understanding of appropriate self-care for persons with diabetes will be crucial in helping to bring this.