The ultimate goal of diabetes therapy is to prevent diabetes complications, such as kidney and heart diseases, in order to improve quality of life and life expectancy. There is excellent evidence that the development of complications can be significantly reduced and their progress and impact limited once they have developed 1 .
Tailoring approaches to the person with diabetes
On a day to day basis most decisions that affect the risk of complications are made by people with diabetes themselves, not by health professionals. Therefore, structured diabetes education to empower people with diabetes, and their carers, to manage their condition is crucial (see Diabetes Education). Lifestyle measures such as eating healthily, maintaining a normal weight, regular physical activity, and not smoking are central to diabetes management, and could lead to improvements in blood glucose, lipids and blood pressure and a reduced risk of complications. In addition, medication often has an important role to play, particularly for the control of blood glucose, lipids and blood pressure.
Glucose lowering oral drugs and insulin
The IDF Global Guideline for Type 2 Diabetes 1 provides an evidence-based framework for setting targets for glucose, blood pressure and lipids, and titrating treatment in order to achieve them. Oral glucose lowering medication is prescribed when lifestyle measures are insufficient to achieve blood glucose control. For most people metformin, which increases sensitivity to insulin, is the drug of first choice followed by a sulfonylurea, which stimulates insulin release. These drugs have been used in the management of diabetes for decades. If these drugs fail to control blood glucose then other options include thiazolidinediones (increase sensitivity to insulin) and alpha glucosidase inhibitors (decrease rate of glucose absorption from the gut). Newer options include the so-called GLP-1 (glucagon-like peptide) mimetics and DPP-4 (dipeptidyl peptidase 4) inhibitors, both of which increase insulin release. At this time experience with these newer agents is limited but they may have a more prominent role in the future.
Overtime the insulin-producing cells within the pancreas of people with type 2 diabetes deteriorate and eventually in most people insulin is needed as other measures are not sufficient to control blood glucose. Insulin analogues may offer some advantages, particularly with respect to hypoglycaemia and weight gain. The introduction of insulin requires close cooperation between the person with diabetes and health carers.
Tailoring approaches to the resources available
Diabetes care does not need to be expensive to be highly effective. In work carried out for the World Bank and World Health Organization 2 interventions for diabetes were classified into three levels based on an assessment of their feasibility and cost effectiveness in developing country settings. Interventions in the first level were found to be highly cost effective or even cost saving, and included moderate blood glucose and blood pressure control and foot care. Recognizing that most people with diabetes live in developing countries, the IDF Global Guideline provides guidance appropriate to three different levels of resource availability.
Screening for undetected diabetes
Type 2 diabetes has a long asymptomatic phase, which frequently goes undetected but during which diabetes complications are developing, and can be present in half or more people with diabetes at diagnosis. Thus, early detection and treatment could help reduce the burden of diabetes complications, and evidence suggests that earlier intensive treatment is indeed effective. However, issues such as who to screen, and what to do with those found to be at high risk of developing diabetes are unresolved. The solutions to these issues will differ between countries, dependent on factors that include the prevalence of undiagnosed diabetes, and the available healthcare resources.
The background paper, Challenges of Type 2 Diabetes, on which this summary is based is available in the Downloads section.
Box 4.3 Areas of individual diabetes care requiring regular review
- Self-care knowledge and beliefs
- Lifestyle adaptation and wishes (including nutrition, physical activity, smoking)
- Psychological status
- Self-monitoring skills and equipment
- Body weight trends
- Blood glucose control
- Blood pressure control
- Blood lipid control
- Cardiovascular risk
- Erectile dysfunction
- Foot condition
- Pre-pregnancy advice (as appropriate)
- Medication review
1: International Diabetes Federation. Global Guideline for Type 2 Diabetes. Brussels: International Diabetes Federation; 2005. http://www.idf.org/node/1285?unode=B7462CCB-3A4C-472C-80E4-710074D74AD3
2: Narayan KV, Kanaya PZA, Williams D, et al. Diabetes: The Pandemic and Potential Solutions. In Jamison D, Breman J, Measham A, et al, editors. Disease control priorities in developing countries. Second Edition. World Bank/Oxford University Press; 2006. p591-604.