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Type 2 diabetes: Rewriting (natural) history

Issue: December 2014

ByEdward C. Chao, DO

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We have recently made great strides in the treatment of diabetes; for example, 12 classes of oral therapeutic agents are now available.

At the same time, as noted by Philips and colleagues, we wasted the first approximately 10 years of the natural history, when the disorder is easiest to treat. The challenge, according to these researchers, is twofold: First, we do not screen often enough. As many as 86 million US residents have prediabetes, and 8 million have unrecognized type 2 diabetes. Second, even after making the diagnosis, we do not treat aggressively enough.

Universal screening

These researchers propose making screening a routine practice. Although each of the tests used to screen for diabetes has its potential advantages and drawbacks, the researchers advocate screening virtually everyone, which is what many health care providers already do to identify gestational diabetes. Another option is a two-step strategy using oral glucose tolerance tests similar to those used for patients who may have gestational diabetes.

Pattern-care management

These researchers also recommend maintaining glycemic control at as close to normal levels as possible, using what they term “pattern care,” as opposed to the current and widely employed stepped-care strategy. Pattern-care management may require the use of basal insulin earlier. The researchers cite the ORIGIN (Outcome Reduction With Initial Glargine Intervention) study, which showed that glargine insulin carried little risk for hypoglycemia in patients early in their natural histories of diabetes.

Some self-monitored blood glucose measures may be needed to help ascertain whether we should target fasting or postprandial glucose levels. Aim for fasting glucose <100 mg/dl and 2-hour postprandial levels <140 mg/dl.

Edward C. Chao

Strive for an HbA1c goal <5.7% or <5.5%. in NHANES and screening for impaired glucose tolerance (SIGT) data, 60% to 70% of patients had normal glucose tolerance when HbA1c levels were <5.7%. aiming for the even lower <5.5% could be an added safeguard against hyperglycemia. That target was used in the Norfolk study, in which higher HbA1c levels were associated with increased all-cause mortality, cardiovascular disease and cancer.

Identifying risk

Biomarkers may hold promise for gauging risk in normoglycemic individuals. One of these is 2-aminoadipic acid (2-AAA), a product of lysine degradation. Investigators recently reported that normoglycemic individuals with plasma concentrations of 2-AAA in the highest quartile had a greater than fourfold risk for developing type 2 diabetes and that 2-AAA was found to possibly amplify insulin secretion in animal models. These results have potentially paradigm-shifting implications both for even earlier identification of at-risk individuals and for treatment.

More studies on 2-AAA and other potential biomarkers, and the screening and management strategy outlined by Phillips and colleagues, would provide needed information on how both individuals and society may benefit from a different approach to diabetes care.