Steven V. Edelman, MD
San Diego Union Tribune, June 8, 2008

It is increasingly clear that to end this epidemic, the current approach for treating type 2 diabetes has to change...
As health care providers, we've traditionally treated diabetes by focusing on decreasing and stabilizing the level of sugar -- known as glucose -- in a patient's blood stream because a strong body of evidence has correlated high blood glucose to an increased risk of complications such as eye, kidney, and heart disease. But last week two very large diabetes studies examining the relationship between glucose levels and heart disease were released that cast some doubt on current diabetes treatment practices.

After exploring the benefits of aggressively lowering blood glucose in patients with type 2 diabetes and heart disease, the studies came to very similar conclusions but with different effects. While both demonstrated that aggressive glucose control did not have any benefit on reducing heart disease, the National Institute of Heath's study found that some people with diabetes who dramatically lowered their blood glucose levels actually had more fatal heart attacks that those who didn't. Overall, this group of high-risk patients, more than one third of whom had already suffered from a heart attack or strokes before the study even began, were found to have more that 20 percent increase in risk of death resulting form this dramatic reduction in blood glucose.

On the other hand, the second study, conducted by the George Institute for International Health in Australia, found no risk of death among type 2 diabetes patients receiving intensive treatment to lower their blood glucose levels. In fact, these patients were actually found to have a 20 percent reduced risk for kidney disease as a result of the treatment.

The contradictory results of these two studies have been widely debated over the past few days by top medical professionals gathered from around the world for the American Diabetes Associations 68th Scientific Sessions. Though differing opinions abound, one thing is clear: the diabetes treatment paradigm is poised for a much needed change.

Managing blood sugar levels alone to treat diabetes is no longer enough. While we can't dismiss the importance of lowering blood glucose levels, it can no longer be the only parameter we're examining--we need to individualize and address the underlying causes of type 2 diabetes and its associated conditions in order to improve health.

Although the exact cause of type 2 diabetes has yet to be conclusively determined, increasing evidence is showing that obesity and type 2 diabetes are inextricably linked, and rising obesity rates are fueling the growing type 2 diabetes epidemic.

We know that excess weight exacerbates health problems like high blood pressure and abnormal cholesterol levels in diabetes patients, often leading to heart disease and kidney failure among other problems. Meanwhile, weight loss, even a modest amount, has been found to help people with diabetes achieve and sustain blood glucose control and live healthier, longer, and more active lives. More invasive weight management options like bariatric surgery have also been shown to successfully treat diabetes.

In short, managing weight is critical for people who have diabetes or are at risk for developing diabetes. Despite the mounting evidence supporting the synergistic benefits of lowering blood glucose levels and weight in patients with type 2 diabetes, weight management is not routinely addressed as part of the treatment paradigm. In fact, many of the diabetes medications most often prescribed by doctors actually cause patients to gain weight. Focusing on both glucose control and obesity when treating tpe 2 diabetes is of vital importance.

Patients need to understand their own roles in lowering both weight and blood glucose. They should start by talking to their health care providers about the best ways to manage weight including diet, exercise, medication and even surgery, in extreme cases. At the same time, caregivers need to take the time to offer their patients advice on healthy living and ensure they prescribe diabetes medications that both lower weight and blood glucose levels. At a minimum, patients should be referred to dietitians, exercise specialists or certified diabetes educators.

Once patients and health care professionals begin working together to manage all aspects of diabetes, we'll see more patients achieving a much better standard of care. This means many San Diegans and other Americans with diabetes can live healthier, happier and more productive lives.

# # #