Field Notes

Experts Say Multifactorial Approach Is Best to Treat Diabetes Mellitus

In a recent commentary published in the American Journal of Managed Care, researchers emphasized the critical need for clinicians to aggressively use a multipronged approach to reduce the risk of complications and premature death from type 2 diabetes.

“There’s an emerging pandemic of type 2 diabetes that’s related to the dramatic increase in obesity, fast becoming the leading avoidable cause of death worldwide,” says Charles H. Hennekens, MD, DrPH, the first Sir Richard Doll professor and the senior academic advisor to the dean in the Charles E. Schmidt College of Medicine at Florida Atlantic University. “People with type 2 diabetes have twice the risk for premature death due to complications from kidney failure, stroke, heart failure, and blindness due to retinopathy.”

The authors stated that intensive glucose control, a cornerstone of treatment for patients with diabetes, is necessary but not sufficient to achieve the maximum benefits in reducing complications and premature death. Clinicians should consider adopting all approaches of proven benefits in screening and managing their patients, which include adjunctive drug therapies to therapeutic lifestyle changes to achieve sustained weight loss, increases in physical activity, and lipid, blood pressure, and glycemic control.

According to National Center of Health Statistics data from a random sample of the US population aged 20 and older, 20% have the metabolic syndrome, a constellation of high blood pressure, obesity, insulin resistance, and high cholesterol. In those aged 50 and older, 40% have the metabolic syndrome, and their 10-year risk of a first coronary event is 16% to 18%.

The authors advised that evidence-based doses of statins, aspirin, angiotensin-converting enzyme inhibitors, or angiotension II receptor blockers should be prescribed as adjuncts to therapeutic lifestyle changes in the aggressive management of diabetes. “The adoption of therapeutic lifestyle changes, which include weight loss and increased physical activity, would preclude the need for pharmacologic interventions for most people with type 2 diabetes,” Hennekens says. “Unfortunately, in the US, many patients prefer the prescription of pills to the prescription of a healthier lifestyle.”

US adolescents today already are heavier, less physically active, smoke more, and have developed type 2 diabetes at a higher rate than their parents’ generation did in their adolescence. Thus, they may become the first US generation since 1950 to have higher rates of cardiovascular disease than their parents.

From a clinical and public health perspective, the authors also expressed their concern on the alarming findings regarding the undertreatment of type 2 diabetes in subpopulations in the United States, such as the mentally ill, as well as in many countries worldwide. They provided best practices guidelines for blood pressure and cholesterol screenings while urging clinicians and policy makers to implement multifactorial interventions.

It’s estimated that if present trends in obesity and physical inactivity continue, it’s likely that one-third of US adults will have diabetes by 2050.

— Source: Florida Atlantic University


Vitamin D With Calcium May Protect Against Bone Fractures

For seniors aged 65 and older, taking a daily supplement of vitamin D with calcium, but not vitamin D alone, can offer some protection against the risk of common bone fractures, according to an updated review from The Cochrane Library.

Broken bones of the hip, wrist, or spine due to osteoporosis or low bone mass affect about 52 million Americans, according to the National Osteoporosis Foundation. About one in two women and one in four men aged 50 and older will break a bone due to their declining bone health.

Vitamin D has been proven essential for maintaining strong bone health. As people age, they tend to get less vitamin D from natural sources, such as sunlight, or foods, such as fish and milk. Supplements often are needed to restore the body’s optimal levels.

Cochrane reviewers evaluated 53 studies with 91,791 participants to determine whether supplements with vitamin D alone or vitamin D with additional calcium offered the best protection against fractures. Seniors were given either vitamin D supplements, including D2 and D3, vitamin D with calcium, or a placebo.

The reviewers, led by Alison Avenell, MD, of the University of Aberdeen in the United Kingdom, concluded that in the doses and formulations that were tested in the included trials, supplements of vitamin D alone are unlikely to lower the risk of hip fractures for older people.
“We didn’t expect to find an effect from vitamin D alone, as this has been a consistent finding from previous reviews,” Avenell says.

Supplements of vitamin D with calcium did, however, reduce the risk of hip fractures in nine of the studies. Among low-risk seniors who live in the community, those who consumed vitamin D with calcium had one less hip fracture per 1,000 older adults per year. For seniors living in high-risk environments of nursing homes and hospitals, there were nine less hip fractures per 1,000 older adults per year.

Avenell says the review supports the recommendation that at-risk older women and men take vitamin D supplements with calcium, noting, however, that people, particularly those with kidney stones, kidney disease, high blood calcium levels, gastrointestinal disease, or who are at risk for heart disease, should seek medical advice before taking supplements.

“I would only suggest calcium and vitamin D for fracture prophylaxis in very high risk populations, such as much older people in institutions such as nursing homes who get no sunlight exposure at all. Even then, the risk of side effects may outweigh any preventive effect. I wouldn’t suggest vitamin D alone,” he says.

— Source: Health Behavior News Service