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Literature Compendium |
Current Concepts in Type 2 Diabetes
Volume 1
Overview of Type 2 Diabetes Pathogenesis, Complications, Risk Reduction, and Lifestyle Intervention
Chapter 2
End-Organ Complications of Inadequately Controlled Type 2 Diabetes
People with Type 2 diabetes have an increased risk of developing both microvascular (eg, retinopathy, nephropathy, and neuropathy) and macrovascular complications (eg, coronary vascular, cerebrovascular, and peripheral vascular disease). Diabetic complications can have a devastating impact on quality of life and reduce life expectancy. The papers in this chapter provide an overview of the burden of diabetes-related complications and underscore the need for new and effective treatments that can achieve tight glycaemic control.
Roglic and colleagues1 used a validated computerized model to estimate the number of worldwide deaths attributable to diabetes in 2000. The model took into account population structure, age- and gender-specific estimates of diabetes prevalence, and available published estimates of relative risk of death in persons with and without diabetes. This excess global mortality attributable to diabetes was estimated to be 2.9 million deaths (approximately 5.2% of all deaths)—1.4 million in men and 1.5 million in women. This estimate of global diabetes-related mortality is roughly 3-fold greater than that derived from international reports based on death-certificate data and may provide a more reliable indicator of the global impact of diabetes. Moreover, as the authors note, because pre-diabetes affects up to 40% of adults and is an independent predictor of mortality, the impact of uncontrolled hyperglycaemia on mortality may be greater than that associated with diabetes alone. These observations provide a strong impetus for achieving glycaemic control in persons with pre-diabetes as well as in those with overt diabetes.
The development and progression of diabetes-related complications may be particularly rapid when the onset of Type 2 diabetes is early. Given the lack of epidemiological studies available to corroborate this hypothesis, Pinhas-Hamiel and Zeitler2 reviewed numerous reports on acute and chronic co-morbidities associated with Type 2 diabetes in young persons and found that the weight of evidence suggests that complications develop and progress more rapidly in persons with diabetes aged 14 to 44 years than in those ≥45 years of age. A wide array of diabetes-related complications was reviewed. Acute complications reviewed included diabetic ketoacidosis, hyperglycaemic hyperosmolar state, and malignant hyperthermia-like syndrome with rhabdomyolysis. Chronic complications and co-morbidities included hypertension, nephropathy, retinopathy, dyslipidaemia, non-alcoholic fatty liver disease, cardiovascular and atherosclerotic complications, neuropathy, psychiatric disorders, health-related quality of life, and complications of pregnancy (maternal risk, fetal and neonatal pathological findings, and long-term effects on offspring).
Smith et al3 performed a longitudinal study using a cohort of participants from the Cardiovascular Health Study (n=282) and a control group matched for age, gender, and race (n=837) to characterize cardiovascular risk associated with new-onset diabetes. The mean age of participants was 76.5 and 76.6 years in the diabetes group and non-diabetes group, respectively. Participants were followed for up to 11 years (mean, 5.9 years). New-onset diabetes was defined by initiation of anti-diabetes medication or by fasting plasma glucose <125 mg/dl without an existing diagnosis of diabetes. The risk of all-cause mortality was 50% greater, and the risk of cardiovascular mortality was twice as great in participants with new-onset diabetes compared with those without diabetes. Mortality risk was elevated within 2 years of the onset of diabetes. Risk estimates were similar in men and women and were greater in African-American individuals than in individuals of other races. These results are important because they suggest that there may be short-term mortality effects that follow the diagnosis of new-onset diabetes in older adults.
Type 2 diabetes was described as a “coronary heart disease (CHD) equivalent” by Juutilainen and colleagues,4 who performed an 18-year extension study of an initial population-based trial designed to compare mortality rates in random populations of people with diabetes and no CHD and those without diabetes but with a history of prior CHD. These investigators followed 2432 participants enrolled in the original trial for a median duration of 17.5 years, representing nearly 35,000 patient-years of study. The results were profound. When prior myocardial infarction was included in the definition of CHD, non-diabetic persons with prior CHD and diabetic persons with no history of CHD had similar mortality rates. When other definitions of CHD (including angina pectoris, ischaemic changes on electrocardiogram, or any evidence of prior CHD) were used, persons with Type 2 diabetes and no prior CHD, particularly women, had a greater mortality rate than those with a history of CHD and no diabetes. These results underscore the need for active management of cardiovascular risk factors in people with Type 2 diabetes.
These 4 papers provide an appreciation of the profound impact that Type 2 diabetes can exert on quality of life and provide a thorough basis for tight glycaemic control as a primary goal in the management of people with Type 2 diabetes.
References
Click to proceed to Chapter 3.
Click to proceed to Chapter 4.
Click to proceed to Programme Evaluation and Post-test.
Click to return to Opening Page.
Click to return to Table of Contents.
Click to return to Introduction.
Click to return to Chapter 1.
The Literature Compendium is funded by an educational grant from Pfizer Inc.
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