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Editor's Message  |   July 2010
Improving the Spectrum of Diabetes Management
Author Notes
  • Dr Freeman is a professor and the chairman of the Division of Endocrinology and Metabolism in the Department of Internal Medicine at the Philadelphia College of Osteopathic Medicine (PCOM) in Pennsylvania. 
  • Address correspondence to Jeffrey S. Freeman, DO, PCOM, 4190 City Ave, Suite 324, Philadelphia, PA 19131-1633. E-mail: jeffreyfreemando@aol.com 
Article Information
Endocrinology / Diabetes
Editor's Message   |   July 2010
Improving the Spectrum of Diabetes Management
The Journal of the American Osteopathic Association, July 2010, Vol. 110, Sii-S1. doi:
The Journal of the American Osteopathic Association, July 2010, Vol. 110, Sii-S1. doi:

“The good physician treats the disease; the great physician treats the patient who has the disease.”

 
Sir William Osler, 1849-1919 
Today, physicians are challenged in many ways to help patients improve their lives. Implementing and managing therapies for diabetes mellitus is an example of this challenge. 
Nearly 24 million individuals in the United States have diabetes mellitus, of whom approximately one-third are undiagnosed.1,2 Additionally, 57 million individuals are classified as having risk for developing diabetes mellitus.2 This number continues to increase in epidemic proportions. With these statistics in mind, as well as overall economic burden and cardiovascular risk, primary care providers must interact with their patients to improve their metabolic milieu and ultimately their risk profile. 
Currently, there are several concerns regarding glycated hemoglobin (HbA1c) levels in patients with type 2 diabetes mellitus (T2DM). Despite efforts to control hyperglycemia, data from the National Health and Nutrition Examination Survey (NHANES) 1999-2000 showed HbA1c levels of less than 7% in only 35.8% of the population and NHANES 2003-2004 in 57% of the population.3 Although this finding shows progress in achieving HbA1c targets, more improvement is needed. 
Additionally, current algorithms provide direction to achieve HbA1c targets. However, these guidelines are generally glucose centric, and factors regarding ethnicity, body mass index, duration of diabetes, age, social economic factors, and other considerations are not included explicitly within these algorithms. 
Cardiovascular disease remains a major cause of mortality affecting approximately 75% of individuals with T2DM.3 Efforts to improve these macrovascular outcomes are assessed and measured in current outcome trials including the Action to Control Cardiovascular Risk in Diabetes (ACCORD),5 the Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE),6 and the Veterans Affairs Diabetes Trial (VADT)7 studies. Practicing physicians are realizing that the macrovascular environment of T2DM is complex with several caveats. 
On November 5, 2009, Frank Lavernia, MD; Jay Shubrook, DO; Frank Svec, MD, PhD; and I participated in a symposium entitled “Incretin-Based Therapies: Bridging the Gap Between Clinical Experiences and Emerging Applications in Type 2 Diabetes.” This event, which was held during the American Osteopathic Association's 114th Annual Osteopathic Medical Conference and Exposition in New Orleans, Louisiana, addressed these issues. The contents of this supplement were developed from that symposium. 
The first article in this supplement, written by myself, provides an epidemiologic basis for enhancing our education and focuses on the management of T2DM. It discusses in detail new ways to measure glycemic control and to implement glucose-centric therapeutics. 
In the next article, Dr Lavernia integrates improvements in glycemic control and reducing cardiometabolic risk. He focuses on the natural progression of T2DM and the link between T2DM and cardiovascular disease. He also discusses several epidemiologic-based studies, particularly the Nurses Health Study,4 that emphasize this relationship. Dr Lavernia also discusses issues surrounding the diagnosis of diabetes and prediabetes, the natural history of T2DM, and the integration of treatment strategies to reduce cardiovascular risk. 
The third article, written by Dr Shubrook, focuses on current cardiovascular outcome studies including data from the ACCORD,5 ADVANCE,6 and VADT7 studies. The complexities and intricacies of both macrovascular and microvascular complications of diabetes are discussed with efforts to apply current interpretation to therapeutics choices. Dr Shubrook defines for the reader the “legacy effect,” which was emphasized from results of the long-term follow-up of the United Kingdom Prospective Diabetes Study (UKPDS)8 and Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications.9 
Dr Svec's focus on the major incretin glucagon-like peptide-1 and its role in glycemic control with and without diabetes comprises the fourth article in this supplement. Dr Svec also discusses the role of glucagon suppression to improve glycemic control and concludes with the current US Food and Drug Administration indications for incretin use. 
The fifth and final segment of the supplement is an illustrative case and panel discussion. Salient points taken from the symposium regarding the patient and therapeutic choices are included. 
This supplement provides an opportunity for primary care providers to reinforce information they are aware of as well as to apply new information for the care of their patients. I hope you will enjoy reading this supplement as much as I have in its preparation. 
 Dr Freeman discloses that he is on the speakers' bureau for GlaxoSmithKline; Merck & Co, Inc; and Novo Nordisk Inc.
 
 This supplement is supported by an independent educational grant from Amylin Pharmaceuticals, Inc, and Lilly USA, LLC.
 
 Editor's Note: A correction to this article was published in the October 2010 issue of JAOA—The Journal of the American Osteopathic Association (2010;110[10]:572). The correction has been incorporated in this online version of the article, which was posted October 2010. An explanation of this change is available at http://www.jaoa.org/cgi/content/full/110/10/572.
 
Network of Minority Research Investigators Workshop [workshop summary]. Bethesda, MD; April 22-23, 2004. http://nmri.niddk.nih.gov/meeting-summaries/4-22-04.pdf. Accessed July 6, 2010.
Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2007. Atlanta, GA: Department of Health and Human Services. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf. Accessed July 6, 2010.
Stolar M. Glycemic control and complications in type 2 diabetes mellitus. Am J Med. 2010;123(3 suppl):S3-S11.
Hu FB, Stampfer MJ, Haffner SM, Solomon CG, Willett WC, Manson JE. Elevated risk of cardiovascular disease prior to clinical diagnosis of type 2 diabetes. Diabetes Care. 2003;25(7):1129-1134. http://care.diabetesjournals.org/content/25/7/1129.long. Accessed July 6, 2010.
Action to Control Cardiovascular Risk in Diabetes Study Group; Gerstein HC, Miller ME, Byington RP, Goff DC Jr, Bigger JT, Buse JB, et al. Effects of intensive glucose lowering in type 2 diabetes [published online ahead of print June 6, 2008]. N Engl J Med. 2008;358(24):2545-2559.
ADVANCE Collaborative Group; Patel A, MacMahon S, Chalmers J, Neal B, Billot L, Woodward M, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes [published online ahead of print June 6, 2008]. N Engl J Med. 2009;358(24):2560-2572.
Duckworth W, Abraira C, Moritz T, Reda D, Emanuele N, Reaven PD, et al; VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes [published corrections appear in N Engl J Med. 2009;361(10):1028 and 2009;361(10):1024-1025]. N Engl J Med. 2009;360 (2):129-139.
UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33) [published correction appears in Lancet. 1999;354(9178):602]. Lancet. 1998;352(9131):837-853.
Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, Orchard TJ, et al; Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med. 2005;353(25):2643-2653. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2637991/?tool=pubmed. Accessed June 15, 2009.