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Redefining treatment success in type 2 diabetes mellitus: Comprehensive targeting of core defects

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The best strategy for managing T2DM is a comprehensive approach that addresses the fundamental core defects plus associated factors that contribute to increased CV risk. Several specialty groups have suggested guidelines and algorithms for the management of T2DM and its comorbidities. These guidelines, including the ADA standards of medical care, the AACE standards in tandem with the American College of Endocrinology guidelines, and the recent joint statement from the ADA and the European Association for the Study of Diabetes (EASD), acknowledge that the core defects of T2DM and the associated CV risk factors (eg, weight gain, obesity, hypertension, dyslipidemia) are important in developing optimal treatment strategies. 1–3 Medical nutrition guidelines advocate weight loss as a key initial step in managing T2DM and the comorbidities that lead to elevated CV risk. 25,26 The National Institutes of Health and the US Department of Health and Human Services/US Department of Agriculture advocate regular physical activity, dietary assessment, and periodic comorbidity and weight assessment for all people, not just those with T2DM or CVD. 26,27

Weight reduction

Evidence in support of effective lifestyle intervention was demonstrated in the Action for Health in Diabetes (Look AHEAD) study. After 1 year, patients with T2DM treated with intensive lifestyle intervention lost an average of 8.6% of their initial weight compared with 0.7% in patients treated only with diabetes support and education ( P < 0.001). The intensive-intervention patients also had a significant drop in HbA1c (from 7.3% to 6.6%; P < 0.001) and were able to reduce their antidiabetes, antihypertensive, and lipid-lowering medications. 28 More recent data from the Look AHEAD study reported that overweight patients with T2DM enrolled in a weight management program experienced significant weight loss, improved physical fitness, reduced physical symptoms, and overall improvement in health-related quality of life. 29 Thus, weight reduction appears to be a key component in reducing CV risk and improving quality of life in most patients with T2DM. 28–30

Hypertension

Hypertension is a major risk factor for microvascular complications and CVD, and may be associated with, or be the underlying result of, nephropathy. 2 BP control is clearly important in reducing the morbidity and mortality associated with T2DM. The recommended BP goal in patients with T2DM is less than 130/80 mm Hg. 1,2

Hyperlipidemia

According to the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III]), diabetes is considered a CHD risk equivalent because it confers a high risk of new CHD developing within 10 years. 31 In addition to the NCEP–ATP III guidelines, the ADA and the AACE have set target levels for lipids in patients with diabetes, including T2DM. 1,2,31 All three organizations have defined 100 mg/dL as the target level for low-density lipoprotein.

HbA1c and lifestyle intervention

Figure 1. Suggested algorithm for the metabolic management of patients with type 2 diabetes mellitus. Clinicians should reinforce lifestyle interventions at every visit and check glycosylated hemoglobin (HbA1c) every 3 months until it is less than 7.0%, and then check it at least every 6 months. The interventions should be adjusted if HbA1c is 7.0% or greater.

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Author and subject indexes: 2009

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