In type 2 diabetes mellitus the determination factors are known (Table 1.6). Only early detection and treatment of the metabolic syndrome will reverse the epidemic trend of type 2 diabetes and its major complications. Among the factors that can be influenced, adverse life style, obesity, and physical inactivity are highly significant [53–56,335–338]. Their correction is the best prevention and causal treatment of type 2 diabetes mellitus.
Societies with increasing prevalence of type 2 diabetes seem to be characterized by a Western life style that includes little physical activity and in which overeating is common. Therefore, prevention of type 2 diabetes should start with population-wide awareness campaigns and counseling about a healthy life style. The management of “civilization-dependent” diseases is not just a medical problem but also a cultural one. The particular situations in different geographic regions must be taken into account. Voluntarily changing a life style which people have found comfortable and pleasant is a life-long task. It is not enough to face people with rational arguments. They need to be offered emotional rewards as well. The ideal would be to make healthy life style fashionable [339].
Various strategies have been proposed in the past [340]. Holistic approaches have been the most promising [337,338].They have proved to be effective under study conditions, but the epidemic trend has not yet been reversed. One reason for the failure may be that intervention is usually targeted at adults, whereas a life style is often shaped in childhood and prevention should be started at that age.
Treatment
Treatment Aims
The primary goals of treatment are identical for all types of diabetes mellitus (Table 1.15).
The impact of diabetes both on the affected subjects and their families and on the health services is important. Mortality is increased. Although recent studies have shown that the prognosis can be improved, it appears to be difficult to replicate the study experiences in the diabetic population in general. For economic reasons this will be impossible in developing regions of the world.
Quality of life is decreased. Reduced life expectancy and the risk of disabling complications frighten many diabetic people, even though their fear may remain unconscious. It is a strain for many diabetic people tointegrate regular self-management into their daily lives. It is burdensome to have to abstain from certain social activities and pleasures, to accept the limitation of fitness and working capacity, and to realize that society tends to consider people with diabetes less reliable and fit for use. Being diabetic may also impair one's chances of employment, and the cost of health insurance may be higher than normal. Psychological problems, both obvious and hidden, and social discrimination are important causes of reduced quality of life.
Table 1.15 Primary goals of diabetes management
| Relief of symptoms |
|---|
| Improvement of quality of life |
| Prevention of acute and chronic complications |
| Reduction of mortality |
| Treatment of accompanying disorders |
| Prevention of discrimination |
| Prevention of psychological, social and economic problems |
Chronic complications of diabetes are a major burden. This is evident in respect of loss of vision, renal failure, or diabetic neuropathies with pain, the diabetic foot syndrome, and autonomic failure such as erectile dysfunction. Concomitant diseases such as the metabolic syndrome also constitute a burden.
The best way to avoid complications of diabetes and early death seems to be near-normal metabolic control, with effective treatment of hypertension, dyslipoproteinemia, and adverse life style (Table 1.16). Both fasting and postprandial hyperglycemia are predictors of chronic complications [3,7,341,342]. For prevention of chronic complications, the Kumamoto study elaborated the following glycemic thresholds: HbA1c <6.5%, fasting blood glucose <110mg/dl (<11.1 mmol/l), 2-hour postprandial glucose >180mg/dl(<10mmol/l).
Basically, the goals shown in Table 1.16 are valid for ail types of diabetes mellitus except for gestational diabetes. They may be modified under certain conditions, for example, if strict metabolic control would mean an increased risk of hypoglycemia, if life expectancy is short for other reasons than diabetes, or in geriatric patients with multiple morbidity in whom diabetes is a second-order problem. Sometimes these goals may also be incompatible with well-being, because changing a comfortable life style will often be necessary to achieve the goals. In these cases a compromise should be agreed upon between the diabetic patient and his/her care team.
Near-normal metabolic control plays a pivotal role not only in chronic, but also in acute hyperglycemia of people who have not had diabetes mellitus. Such conditions occur frequently after major surgery or other major somatic stress such as multiple trauma or severe burns. In the past, these critically ill people were usually treated only in the presence of hyperglycemia exceeding 200mg/dl(11 mmol/l) with the aim of keeping blood glucose below this level. This standard of treatment is insufficient, since a recent study has shown that lowering morning blood glucose from an average of 153 mg/dl (8.5 mmol/l) to 103 mg/dl (5.7 mmol/l) reduces mortality by almost 50% [343]
Table 1.16 Medical goals of diabetes management according to Deutsche Diabetes Gesellschaft [344]
| Capillary blood glucose | ||
| Postprandial | 130–160 mg/dl | 7.2–8.9 mmol/l |
| Fasting | 90–120 mg/dl | 5.0–6.7 mmol/l |
| Bedtime | 110–140mg/dl | 6.1–7.8mmol/l |
| HbA,1c (%) | 6.5 | |
| Triglycerides(mg/dl) | ≤150mg/dl | ≤1.71 mmol/l |
| LDL cholesterol (mg/dl) | ≤130 mg/dl | ≤3.45 mmol/l |
| HDL cholesterol (mg/dl) | ≥40 mg/dl | ≥1.04 mmol/l |
| BMI (female/male) | 25/26 | |
| Blood pressure (mmHg) | ≤140/85120/80a | |
| Healthy life style | ||
| Well-being |
a In subjects with microangiopathy
Nonpharmacological Treatment
The goals of treatment can seldom be attained by conventional methods of patient care, where the doctor makes out a prescription and the patient has to follow it. In order to keep metabolism in a near-normal range, it is necessary to check actual glycemic control frequently, often several times a day. Values that are too high or too low must be corrected, and to plan treatment according to the events of the day. These daily therapeutic measures are unpredictable and cannot be carried out by doctors and their team, only by the diabetic subjects (or those around them) themselves. Consequently, people with diabetes should no longer be seen as “patients” “suffering from” their disease, but must become active partners of their doctors (Table 1.17).