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Race and Genetic Ancestry in Medicine U.S. health inequities won’t be eliminated by abandoning the use of race and ethnicity in research and clinical practice, since these variables capture key epi...

Despite ongoing advances in medications, insulin delivery systems, and glucose monitoring technologies, diabetes control remains suboptimal in many individuals with this disease.1 In addition to the clinical consequences resulting from poor control is the ever-increasing financial burden on individuals, health systems, and society.2 In its latest report, the American Diabetes Association (ADA) estimated the total estimated cost of diagnosed diabetes in 2017 to be $327 billion.2 Although the direct cost of treating complications (hospitalizations, emergency room visits, and nondiabetes prescription medications) and the indirect costs associated with lost/reduced productivity account for ∼73.1% of the total diabetes cost, many public and private payers continue to focus much of their cost-cutting efforts on reducing the costs of diabetes supplies, which account for only 1.1% of the total cost. Examples of these questionable efforts can be found in the restrictive eligibility criteria for coverage of continuous glucose monitoring (CGM). Specifically, the requirements are that eligible individuals must have type 1 diabetes (T1D) and be able to document routine performance of at least four fingerstick blood glucose tests per day. The Centers for Medicare and Medicaid Services (CMS) explicitly requires this level of testing for Medicare beneficiaries to qualify for CGM coverage, as do 11 of 36 state Medicaid programs that provide CGM coverage. Requiring documentation of >4 blood glucose tests per day is clearly enigmatic given that the Medicare coverage policy only pays for three test strips per day for insulin-treated beneficiaries. Although Medicare coverage includes both T1D and intensively treated type 2 diabetes (T2D), many state Medicaid programs do not match such coverage. A comprehensive Internet search found that 13 state programs limit CGM use to individuals with T1D and documented history of 4 × /day blood glucose testing (Table 1). Three programs cover both T1D and insulin-requiring T2D but with the minimum blood glucose monitoring restriction. Four programs cover T1D with no blood glucose monitoring restriction, and only one state covers both type 1 and insulin-requiring diabetes with no blood glucose restriction. Eligibility for CGM in the remaining 14 State Medicaid programs is not specified or accessible according to our Internet search. Table 1. Medicaid Coverage for Continuous Glucose Monitoring Use

Numerous randomized controlled trials (RCTs) have demonstrated the glycemic benefits of continuous glucose monitoring (CGM) in management of type 1 diabetes (T1D) and type 2 diabetes. Although RCTs remain the gold standard clinical study design, findings from these trials do not necessarily reflect the effectiveness of CGM or reveal the feasibility and wider applications for use in broader real-life settings. This review evaluates recent real-world evidence (RWE) demonstrating the value of CGM to improve clinical outcomes, such as avoidance of severe hypoglycemic and hyperglycemic crises, and improved measures of psychological health and quality of life. Additionally, this review considers recent RWE for the role of CGM to enhance health care resource utilization, including prediction of T1D and applications in gestational diabetes, chronic kidney disease, and monitoring during surgery.

Optimizing glycemic control remains a shared challenge for clinicians and their patients with diabetes. Flash continuous glucose monitoring (CGM) provides immediate information about an individual’s current and projected glucose level, allowing users to respond promptly to mitigate or prevent pending hypoglycemia or hyperglycemia. Large randomized controlled trials (RCTs) have demonstrated the glycemic benefits of flash CGM use in both type 1 and type 2 diabetes. However, whereas RCTs are mostly focused on the efficacy of this technology in defined circumstances, real-world studies can assess its effectiveness in wider clinical settings. This review assesses the most recent real-world studies demonstrating the effectiveness of flash CGM use to improve clinical outcomes and health care resource utilization in populations with diabetes.

Race and Genetic Ancestry in Medicine U.S. health inequities won’t be eliminated by abandoning the use of race and ethnicity in research and clinical practice, since these variables capture key epi...

The use of personal continuous glucose monitoring (CGM) has expanded dramatically among individuals with diabetes. CGM systems provide retrospective data, as well as the current glucose value and trend arrow data, which indicate the direction and velocity of changing glucose. In 2017, Aleppo and colleagues developed a simplified approach for adults with diabetes to safely adjust rapid-acting insulin doses using trend arrow information in the Dexcom G5 CGM system. Since then, the FreeStyle Libre and FreeStyle Libre 14-day CGM systems have become available in the United States; however, guidance on using trend arrow data that take the unique features of these systems into consideration is lacking. Specifically, the FreeStyle Libre systems do not have automatic alarms, which impact how the system and trend arrow data are used. The Endocrine Society convened an expert panel to address this gap and develop an approach to adjusting rapid-acting insulin doses for adults using trend arrows in the FreeStyle Libre systems. We based our approach on previous work and expanded upon engagement and scanning recommendations, and we incorporated pre-exercise planning specific to these systems. Our approach provides insulin dose adjustments as discrete insulin units based on an individual’s insulin sensitivity and directionality of the trend arrow. We focus on the needs of patients treated with multiple daily injections because these individuals currently make up a greater proportion of individuals on intensive insulin therapy. Our recommendations are intended to provide a safe, practical approach to using trend arrows in the FreeStyle Libre systems.

Diabetes is epidemic worldwide and places a huge burden on healthcare systems. The majority of the cost of type 2 diabetes (T2D) is related to hospitalization and the management of complications, and these also have a negative impact on the individual’s quality of life. The Berlin Declaration is a global call for early action for the identification of high risk individuals, prevention of T2D and the prevention of complications in those with T2D, through prevention, early detection, early control and early access to the right multidisciplinary interventions. This should empower people to take action to prevent T2D and its complications.

Diabetes is a major global epidemic and places a huge burden on healthcare systems worldwide. The complications of type 2 diabetes (T2D) and related hospitalizations are major contributors to this burden, and there is strong evidence that the risk for these can be reduced by early action to identify and prevent progression of people at high risk of T2D and ensure tight glycemic control in those with established disease. In response to this, the Berlin Declaration was developed by four working groups of experts and ratified by healthcare professionals from 38 countries. Its aim is to act as a global call to action for early intervention in diabetes, in addition to providing short-, medium- and long-term targets that should be relevant to all nations. The Berlin Declaration focuses on four aspects of early action, and proposes actionable policies relating to each aspect: early detection, prevention, early control and early access to the right interventions. In addition, a number of treatment targets are proposed to provide goals for these policies. To ensure that the suggested policies are enacted in the most effective manner, the support of specialist care professionals is considered essential.

Advances in understanding diabetes mellitus (DM) through basic and clinical research have helped clarify and reunify a disease state fragmented into numerous etiologies and subtypes. It is now understood that a common pathophysiology drives the diabetic state throughout its natural history and across its varied clinical presentations, a pathophysiology involving metabolic insults, oxidative damage, and vicious cycles that aggravate and intensify organ dysfunction and damage. This new understanding of the disease requires that we revisit existing diagnostics and treatment approaches, which were built upon outmoded assumptions. 'The Common Pathophysiologic Origins of Diabetes Mellitus and its Complications Construct' is presented as a more accurate, foundational, and translatable construct of DM that helps make sense of the hitherto ambiguous findings of long-term outcome studies.

The current classification system presents challenges to the diagnosis and treatment of patients with diabetes mellitus (DM), in part due to its conflicting and confounding definitions of type 1 DM, type 2 DM, and latent autoimmune diabetes of adults (LADA). The current schema also lacks a foundation that readily incorporates advances in our understanding of the disease and its treatment. For appropriate and coherent therapy, we propose an alternate classification system. The β-cell–centric classification of DM is a new approach that obviates the inherent and unintended confusions of the current system. The β-cell–centric model presupposes that all DM originates from a final common denominator—the abnormal pancreatic β-cell. It recognizes that interactions between genetically predisposed β-cells with a number of factors, including insulin resistance (IR), susceptibility to environmental influences, and immune dysregulation/inflammation, lead to the range of hyperglycemic phenotypes within the spectrum of DM. Individually or in concert, and often self-perpetuating, these factors contribute to β-cell stress, dysfunction, or loss through at least 11 distinct pathways. Available, yet underutilized, treatments provide rational choices for personalized therapies that target the individual mediating pathways of hyperglycemia at work in any given patient, without the risk of drug-related hypoglycemia or weight gain or imposing further burden on the β-cells. This article issues an urgent call for the review of the current DM classification system toward the consensus on a new, more useful system.

Canagliflozin, a sodium-glucose co-transporter 2 inhibitor, enhances urinary glucose excretion through an insulin-independent mode of action, and improves glycemic control in patients with type 2 diabetes mellitus (T2DM). This study assessed the efficacy and safety of canagliflozin across racial groups.The efficacy of canagliflozin 100 mg and 300 mg was evaluated by racial group using data pooled from four placebo-controlled phase 3 studies and two placebo-controlled sub-studies of a population of patients with inadequately controlled T2DM (N = 4158). Least-squares mean changes from baseline were calculated for hemoglobin A1c (HbA1c), systolic blood pressure (SBP), body weight (BW), cholesterol, and triglycerides. Safety/tolerability evaluation included reporting of general and prespecified adverse events (AEs).A total of 75% of patients were White, 13% were Asian, 4% were Black/African American, and 8% were 'Other' (American Indian, Alaskan Native, mixed race, Native Hawaiian or other Pacific Islander, not reported, and unknown). Baseline demographics were similar for these groups. Dose-related reductions in HbA1c, BW, and SBP were observed with both canagliflozin doses in all racial groups. Canagliflozin was generally safe and well tolerated. Treatment with canagliflozin was associated with an increased rate of genital mycotic infections (GMIs) and urinary tract infections (UTIs) in all racial groups. GMIs were observed more often in Black/African American males and males from the 'Other' racial group, whereas UTIs and osmotic diuresis-related AEs were less common in Asians. Key study limitations include the high proportion of White patients compared with other racial groups and the fact that included studies were not powered to evaluate racial differences.Canagliflozin was generally well tolerated and consistently associated with reductions in HbA1c, BW, and SBP in patients with T2DM independent of racial background. (ClinicalTrials.gov numbers: NCT01081834; NCT01106677; NCT01106625; NCT01106690; and NCT01032629.).

Background and objectives Colesevelam significantly lowers cholesterol in patients with hypercholesterolemia, and both cholesterol and hemoglobin A1C (A1C) in patients with type 2 diabetes mellitus (T2DM). The purpose of this post hoc analysis was to evaluate the efficacy and safety/tolerability of colesevelam in older (≥65 years) and younger (

We thank Drs. Kalra and and Baruah for their comments (1) on our article (2) in an effort improve the utility of our proposed β-cell–centric classification. We agree that “treatment” is more important than “classification.” We find it frustrating that governments and insurers often think otherwise, limiting therapies of choice on the basis of labels of diabetes mellitus (DM) that are not optimally useful. Thus a “precision medicine” classification system that identifies specific causes of hyperglycemia and their corresponding therapies augurs for payment coverage parity across the range of glucose-lowering medications for patients with any form of DM. Although the insulin-to-glucagon ratio (IGR) construct is interesting and could serve as a “marker” to help choose between various therapies in our approach, our …

Advances in heart failure treatment have not necessarily translated into equity in improved outcomes for African Americans. Heart failure in African Americans is characterized by a higher prevalence, especially at younger ages; more-adverse course with more frequent hospitalizations; and higher mortality rates compared to the general population. Despite this distinct disease profile, African Americans are remarkably underrepresented in large heart failure trials. This paper reviews the unique course of heart failure in African Americans and discusses treatment in the context of clinical trial evidence. African Americans with heart failure may respond differently to some standard therapies compared to whites, but low levels of enrollment of AAs in large clinical trials preclude valid conclusions in certain cases. An important exception is the African American Heart Failure Trial (AHeFT), a well-designed, prospective, randomized, placebo-controlled, double-blind study, that added a combination of fixed-dose isosorbide dinitrate/hydralazine (ISDN/ HYD) to standard therapy and showed a 43% improvement in survival and a 33% reduction in first hospitalizations. Despite compelling evidence from AHeFT, post hoc secondary analyses, and recommendations from current practice guidelines, ISDN/HYD remains underutilized in African Americans with heart failure. In this paper, we put forth a call to action for racial equity in clinical research and treatment in African Americans with heart failure.

Purpose Current evidence shows early initiation of insulin therapy in type 2 diabetes mellitus (T2DM) improves glycemic control, responsiveness to subsequent oral antidiabetic therapies, β-cell function, and possible cardiovascular outcomes. The American Diabetes Association (ADA)/ European Association for the Study of Diabetes (EASD) 2008 algorithm introduces insulin therapy earlier in the treatment of T2DM with prompt intensification to achieve therapeutic goals. Agent selection and insulin regimens are based on patient A1C levels and willingness to monitor blood glucose, use of previous medications, blood glucose patterns, diet, and lifestyle. Practical considerations offered for diabetes educators and clinicians include creating strategies for early initiation of insulin, addressing patients’ psychosocial barriers and quality of life concerns, understanding pharmacokinetic properties of insulin formulations, selecting appropriate therapy and patient-based regimens, and intensifying therapy to achieve glycemic control. Conclusions Diabetes education, including intentional curriculum design, for patients with T2DM who are initiating or intensifying insulin therapy, addresses patient barriers to care, reduces the burden of treatment, improves adherence to treatment protocols, and helps optimize clinical outcomes.

In patients with type 2 diabetes, a progressive decline in glycemic control exacerbates the microvascular (retinopathy, neuropathy, and nephropathy) and macrovascular (cardiovascular disease, stroke, and peripheral arterial disease) complications associated with this disease. In a consensus statement, the American Diabetes Association and the European Association for the Study of Diabetes stated that the main goal of antidiabetes therapy is to achieve glycemic control, defined as a glycated hemoglobin of < 7%, although goals should be individualized to each patient, especially in patients at highest risk of cardiovascular disease events. However, because type 2 diabetes is a progressive disease, the response to oral antidiabetes (OAD) agents declines over time and the majority of patients are unable to maintain glycemic control, thus necessitating additional therapy. This requirement for additional antidiabetes therapies as the disease progresses suggests that more aggressive and earlier use of synergistic therapies may help achieve and prolong glycemic control. This review examines the efficacy of OAD therapies to address the unmet need for prompt and maintained glycemic control to the recommended goal in patients with type 2 diabetes, the factors that can affect the glycemic response to the various classes of OAD agents, and ways in which the management of hyperglycemia can be improved in patients with type 2 diabetes.

James R Gavin, III1, Helena W Rodbard2, Kathleen M Fox3, Susan Grandy4 for the SHIELD Study Group1Emory University School of Medicine, Atlanta, GA, USA; 2Endocrine and Metabolic Consultants, Rockville, MD, USA; 3Strategic Healthcare Solutions, LLC, Monkton, MD, USA; 4AstraZeneca LP, Wilmington, DE, USAObjectives: This investigation evaluated the role of obesity in health status and behaviors for weight management and exercise among individuals with type 2 diabetes mellitus (T2DM) or cardiometabolic risk factors.Methods: Self-reported health status, exercise behaviors, and weight management were assessed in the SHIELD study for respondents with T2DM or high risk (HR) for diabetes (ie, ≥3 of the following: abdominal obesity, body mass index [BMI] ≥28 kg/m2, self-reported diagnosis of dyslipidemia, hypertension, or history of cardiovascular disease). Respondents were stratified into three BMI categories

Objective To discuss the appropriate use of oral therapies to achieve and sustain glycemic targets in patients with type 2 diabetes. Methods The stages in the development and progression of type 2 diabetes are reviewed, and the limitations of single-drug therapy are addressed. Results The development of diabetes is a staged progression; affected patients show evolution through numerous stages of glucose intolerance before clinical diabetes manifests. Beta cell function continues to deteriorate until absolute failure occurs; however, other factors, such as glucose and lipid toxicities, insulin resistance in peripheral tissues, and loss of the first-phase insulin response, further impair the body’s ability to regulate release of insulin in response to glucose. Traditional treatment algorithms often fail to address the progressive, multifaceted nature of type 2 diabetes, with its numerous related abnormalities. Combination therapy with orally administered agents can be used to manage glucose concentrations and other risk factors safely and effectively. Conclusion The therapeutic goal in type 2 diabetes is to achieve and maintain a physiologic profile as close to normal as possible. This outcome necessitates treatment of multiple defects with use of various combinations of orally administered agents. Clinicians should focus on effective treatment of these defects to achieve established targets. (Endocr Pract. 2006;12[Suppl 1]:93-97)

The prevalence of type 2 diabetes has grown to epidemic proportions in the United States and is disproportionately higher in certain ethnic groups. African Americans, Hispanic Americans, Native Americans, and Asian Americans have an approximately two‐fold higher rate of type 2 diabetes than whites. The increased prevalence of type 2 diabetes mirrors the growing rates of overweight and obese persons in the United States. While the highest rate of diabetes occurs at age 60 years and older, the fastest growing segment of the population with type 2 diabetes is younger than age 39 years. Because most diabetes‐related deaths are due to cardiovascular disease, an aggressive management strategy for type 2 diabetes must address both coronary heart disease risk factor reduction and glycemic control. Both the microvascular and macrovascular complications of type 2 diabetes can be prevented or slowed with aggressive therapy. Glycemic dysfunction can be moderated by aggressive combination therapy that focuses on the pathophysiology of diabetes in an individual patient and combines two or three oral agents, such as an insulin sensitizer with an insulin secretagogue or two insulin sensitizers with different loci of action. The goal of glycemic control is reduction of glycated hemoglobin to 40 mg/dL for men and >50 mg/dL for women, and decrease triglyceride levels to

There is overwhelming evidence that the renin-angiotensin system plays a significant role in the pathophysiology of hypertension and target organ damage. Agents that regulate the renin-angiotensin system, such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, and aldosterone antagonists, are not only effective antihypertensive agents but can prevent target organ damage. Although diuretics remain the agents of first choice for the treatment of hypertension in African Americans, ACE inhibitors have a clear role in the management of these patients. ACE inhibitors (usually when used with a diuretic) have been shown to reduce morbidity and mortality in a wide range of patient groups. ACE inhibitors are infrequently used in African Americans because of a belief that these agents are ineffective in this racial group; however, when adequate dosing and appropriate combinations are used, ACE inhibitor therapy provides effective blood pressure control. In particular, the addition of diuretics to ACE inhibitor therapy ameliorates the racial differences in efficacy seen when ACE inhibitors are administered as monotherapy. Although further confirmation in additional clinical trials is required, increased use of these agents in African Americans will likely result in a reduction in target organ damage.

The role of postprandial hyperglycemia in the etiology of diabetes-related complications and outcomes, although still being elucidated, is greater than previously thought. Acute glucose elevations after meal ingestion are associated with a variety of glucose-mediated tissue defects-oxidative stress, glycation, and advanced glycation end product formation-which have far-reaching structural and functional consequences for virtually every human organ system. Lowering glycosylated hemoglobin to levels that prevent or delay these complications can be achieved only by reducing both postprandial and fasting plasma glucose levels. The alpha-glucosidase inhibitors (acarbose, voglibose, miglitol) have been effective in delaying the digestion and absorption of carbohydrates, thus diminishing the postprandial surge in blood glucose levels without loss of calories. However, greater emphasis needs to be placed on the measurement of postprandial glycemia, so that readings can be used to guide treatment.

T he U.S. Department of Health and Human Services' National Diabetes Education Program (NDEP) is the leading federal government public education program that promotes diabetes prevention and control. Based on the scientific results of the Diabetes Control and Complications Trial,1 NDEP was launched in 1997 with a mission to reduce the morbidity and mortality associated with diabetes. To fulfill that mission, NDEP translates the latest science and disseminates the message that type 2 diabetes is serious, common, and costly, yet controllable and preventable. NDEP is jointly sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention, with the support of > 200 partner organizations. Health care professionals need to know about current advances in diabetes management and prevention and require access to the most appropriate and effective tools and materials to assist them in administering the most effective care. NDEP provides a wealth of information and tools through three major campaigns: 1. Control Your Diabetes. For Life. This is a comprehensive information campaign focusing on tips and strategies for effective diabetes management. 2. Be Smart About Your Heart: Control the ABCs of Diabetes. This emphasizes the link between diabetes and cardiovascular disease. 3. Small Steps. Big Rewards. Prevent Type 2 Diabetes. This is the first national diabetes prevention effort. In view of the spiraling epidemic of diabetes in …

Type 2 diabetes has been definitively characterized as one of the most physiologically complex and heterogeneous metabolic known diseases. The extraordinary depth of knowledge that has been achieved regarding the pathophysiology has helped to stimulate an explosive array of therapeutic regimens and monitoring tools for improving outcomes in this disease. Indeed, the clinical narrative about ‘control’ of diabetes has shifted markedly in the last two years, away from a focus on glucose-mediated vascular complications to defining diabetes control as cardiovascular risk reduction and end organ protection. The new tools for management coupled with new pathophysiologic insights have brought a tide of good news for the millions of people living with type 2 diabetes.

The authors present a case of a 46-year-old woman with type 2 diabetes mellitus who has been on a treatment regimen involving diet, exercise, and metformin. After 2 years of treatment, she has a body mass index of 35 and a glycosylated hemoglobin level of 8.0%, and this level is increasing. Her physician recommends adding a glucagon-like peptide-1 (GLP-1) receptor agonist to her treatment regimen, prompting her to ask several questions. The authors present these questions along with proposed answers, highlighting the practical application of GLP-1 receptor agonists in the context of common patient concerns.

Control of blood glucose levels and restoration of pancreatic islet function are among the goals of physicians seeking to improve outcomes in patients with type 2 diabetes mellitus (T2DM). A growing body of evidence supports the use of incretins to achieve these goals, and current guidelines recommend earlier and more frequent use of these agents. However, in patients with T2DM, treatment paradigms should always be individualized. The author discusses issues for physicians to consider when adjusting T2DM therapy, including patient comorbidities, glucose control patterns, and potential adverse effects. The importance of patient education and practical points for initiating a glucagon-like peptide-1 receptor agonist are also reviewed.

Although the pathogenesis of the diabetes mellitus syndrome remains poorly understood, both insulin-dependent diabetes mellitus and non-insulin-dependent diabetes mellitus predispose the individual to a similar spectrum of complications, including hypertension, macrovascular and microvascular disease, cataracts cardiomyopathy, neuropathy, and premature aging, suggesting that these complications develop along a pathway common to both diabetic conditions. Yet not all diabetic persons are affected by all of these complications or to the same degree. What causes this marked variability in the clinical manifestations of the diabetes syndrome remains an enigma. Accumulating data from animal models of diabetes and from studying patients with diabetes reveal that intracellular calcium levels are increased in most tissues. The activities of the membrane, adenosine triphosphatase (ATPase) associated cation pumps, which determine intracellular calcium level (i.e., calcium-ATPase and [sodium + potassium]-ATPase), are also altered. The nature of the alteration is often tissue specific and may depend on the level of blood glucose or insulin, or both. In this review we discuss the potential contribution of these changes in intracellular calcium regulation, whether acquired or genetically determined, to the pathogenesis of the diabetes syndrome, to the abnormalities in insulin secretion and action (mainly in non-insulin-dependent diabetes), and to the complications of both diabetes syndromes. Altered intracellular calcium metabolism may represent a common, underlying abnormality linking the metabolic, cardiovascular, ocular, and neural manifestations of the diabetic disease process.

Background Self-management is the cornerstone of diabetes control and prevention of complications; however, it is undetermined whether differences in intention to adopt healthy lifestyles and actual healthy behavior exist across race/ethnic groups. This study evaluated the differences across racial-ethnic groups in self-reported medical advice received and health intentions and behaviors among adults with type 2 diabetes mellitus. Methods A cross-sectional analysis of the 2007 SHIELD US survey ascertained self-reported health intentions and behaviors for regular exercise, diet, and weight management among Non-Hispanic Caucasian (n = 2526), Non-Hispanic African-American (n = 706), and Hispanic (n = 179) respondents with type 2 diabetes. Results A similar proportion of respondents from each race-gender group (43%-56%) reported receiving healthcare advice to increase their exercise (P = 0.32). Significantly more minorities reported an intention to follow the exercise recommendation compared with Non-Hispanic Caucasians (P = 0.03). More Non-Hispanic African-American (29%) and Hispanic (27%) men reported exercising regularly compared with other race-gender groups (P = 0.02). Significantly more Non-Hispanic Caucasian women (74%) and Hispanic women (79%) reported trying to lose weight compared with other groups (P < 0.0001). Conclusions Differences in health intentions and healthy behaviors were noted across race-gender groups. More Non-Hispanic African-American men reported an intention to follow advice on exercising and self-report of exercising regularly was also higher compared with other race-gender groups. More Hispanic men reported high physical activity levels than other groups. Despite an increased willingness to follow healthcare recommendations for diet, >50% of respondents were obese among all race-gender groups.

The incidence and prevalence of type 2 diabetes mellitus (T2DM) have reached epidemic proportions in the United States. In addition to growing numbers of individuals in whom T2DM has been diagnosed, in numerous others T2DM or prediabetes remains undiagnosed or is likely to develop in the near future. Identification of individuals at risk for T2DM, as well as those who may already have the disease but in whom it has not yet been diagnosed, is a key element in reducing the overall burden of this disease. Early initiation of treatment can prevent or delay disease progression and reduce the risk for diabetes-related complications. Achieving evidence-based clinical goals by implementing effective management strategies substantially reduces the risk of morbidity and mortality and ultimately improves patient outcomes. A review of the latest and most effective approaches to T2DM management and practical suggestions for implementing treatment strategies in order to provide optimal T2DM care will be presented.

The incidence and prevalence of type 2 diabetes mellitus (T2DM) in the United States continue to rise, and the disease has become an enormous health concern. While effective glycemic management reduces the risk of diabetes-related complications in patients with T2DM, many patients are unable to reduce their glucose levels to target goals. The authors review key elements in the management of T2DM with an emphasis on achieving and maintaining glycemic control. Strategies are offered to provide practical solutions to the challenges faced by healthcare providers and patients with T2DM. The importance of implementing evidence-based practice guidelines while empowering patients to participate in self-management of their disease is highlighted.

Background Body mass index (BMI) is often used as an objective surrogate estimate of body fat. Increased BMI is directly associated with an increase in metabolic disease, such as type 2 diabetes mellitus (T2DM). The Stunkard Figure Rating Scale (FRS) is a subjective measure of body fat, and self-perceptions of body image conceivably impact the development and treatment of T2DM. This study examined the self-perception of body image to various levels of BMI among those with T2DM. Methods Respondents (n = 13,887) to the US S tudy to H elp I mprove E arly evaluation and management of risk factors L eading to D iabetes (SHIELD) 2006 survey self-reported their weight and height for BMI calculation. On the gender-specific Stunkard FRS, respondents selected the figure most closely resembling their body image. Spearman correlation was computed between perceived body image and BMI for men and women separately. Student's t-test analysis compared the mean BMI differences between respondents with and without T2DM. Results Men with T2DM did not significantly differ from men without diabetes mellitus in mean BMI per body image figure except at the extremes in body figures. Women with T2DM had a significantly higher BMI for the same body figure compared with women without diabetes mellitus for most figures (p < 0.05). Conclusions Individuals, particularly women, with T2DM may differ in their perception of body image compared with those without diabetes mellitus. It is unclear if these perceived differences increase the risk of T2DM, or if the diagnosis of T2DM alters body image perceptions.

Alan J. Garber, MD, PhD, FACE, Yehuda Handelsman, MD, FACP, FACE, Daniel Einhorn, MD, FACP, FACE, Donald A. Bergman, MD, FACE, Zachary T. Bloomgarden, MD, FACE, Vivian Fonseca, MD, FACE, W. Timothy Garvey, MD, James R. Gavin III, MD, PhD, George Grunberger, MD, FACP, FACE, Edward S. Horton, MD, FACE, Paul S. Jellinger, MD, MACE, Kenneth L. Jones, MD, Harold Lebovitz, MD, FACE, Philip Levy, MD, MACE, Darren K. McGuire, MD, MHSc, FACC, Etie S. Moghissi, MD, FACP, FACE, and Richard W. Nesto, MD, FACC, FAHA

Current clinical guidelines for diabetes care encourage self-monitoring of blood glucose (SMBG) to improve glycemic control. Specific protocols remain variable, however, particularly among non-insulin-using patients. This is due in part to efficacy studies that neglect to consider (1) the performance of monitoring equipment under real-world conditions, (2) whether or how patients have been taught to take action on test results, and (3) the physiological, behavioral, and social circumstances in which SMBG is carried out. As such, a multidisciplinary group of specialists, including several endocrinologists, a health psychologist, a diabetes nurse practitioner, and a patient advocate (the Panel), discuss within this review article how the potential of SMBG might be fully realized in today's healthcare environment. The resulting recommendations cover technological, clinical, behavioral, and research considerations with the aim of achieving short- and long-term benefits, ranging from fewer hypoglycemic episodes to lower complication-related costs. The panel also made suggestions for designing future studies that increase the ability to discern optimal models of SMBG utilization for individuals with diabetes who may, or may not, use insulin.

Type 2 diabetes mellitus (T2DM) and its complications must be managed by using a comprehensive, or global, approach to treatment. The author describes the case of a white man, aged 51 years, with T2DM that was diagnosed 3 years earlier. The patient was obese and had a history of chronic low back pain. He also had diagnosed hypertension, decreased vibratory sensation in the feet, an S4 atrial gallop, trace ankle edema, degenerative joint disease in the knees, and decreased range of motion in the lumbar spine. Other findings at the patient's initial visit included hyperglycemia, microalbuminuria, and lipid abnormalities. Initial treatment included metformin; a nonsteroidal anti-inflammatory drug (naproxen); a thiazolidinedione (rosiglitazone maleate); a thiazide diuretic (hydrochlorothiazide); an angiotensin-converting enzyme inhibitor (enalapril); and low-dose aspirin. At 6-month follow-up, the patient continued to have elevated glycosylated hemoglobin, hypertension, dyslipidemia, and excess weight. Additional treatment strategies consisted of pioglitazone hydrochloride; metformin in combination with the dipeptidyl peptidase IV inhibitor sitagliptin phosphate; a statin (atorvastatin hydrochloride); and enrollment in a diet and exercise program. Results at 12-month follow-up included a substantial decrease in glycosylated hemoglobin and improved hypertension and dyslipidemia. The patient was successfully treated across the full range of global cardiovascular risk reduction.

Because skeletal muscle plays a major role in glucose disposal, it may be the primary site of insulin resistance in non-insulin-dependent diabetes mellitus (NIDDM). Rates of glycogen synthesis (GS), glucose utilization via glycolysis, glycolytic utilization (GU), and glucose transport (GT) were studied in epitrochlearis muscles (EMs) obtained from 10-wk-old nonfasted Sprague-Dawley rats in which NIDDM was neonatally induced with streptozocin. Plasma glucose in NIDDM rats was elevated (P < 0.001), whereas plasma insulin was similar in NIDDM and control rats. No differences in muscle weight, protein, glycogen, ATP, phosphocreatine, lactate, lactate-pyruvate ratios, or glucose-6-phosphate were noted in EMs of control and NIDDM rats. EMs were incubated in medium containing 5.6 or 11.2 mM glucose with tracer D-[5-3H]glucose and insulin from 0 to 7.18 × 10−7 M for 1 or 2 h, and GS, GT, and GU were evaluated. Similar rates of basal (non-insulin-mediated) and insulin-stimulated GS, GU, and GT were observed in EMs of NIDDM and control rats incubated in 5.6 mM glucose for 2 h. Insulin doseresponse curves revealed similar sensitivities and responsiveness. Increasing glucose concentration (from 5.6 to 11.2 mM) induced significant increases in basal rates of GS, GU, and GT in EMs of control but not NIDDM rats. Insulin dose-response curves for GS and GT revealed decreased sensitivity and no change in responsiveness in EMs of control and NIDDM rats, even though GU of EMs of NIDDM rats was significantly lower at basal and all other insulin concentrations. These data revealed that both insulin resistance and glucose resistance contribute to the impaired glucose metabolism in EMs of the NIDDM rat.

Insulin increases (Ca2+ + Mg2+)-ATPase activity in cell membranes of normal rats but fails to do so in membranes of non-insulin-dependent diabetic (NIDD) rats. The loss of regulatory effect of the hormone on the enzyme might contribute to the insulin resistance observed in the NIDD animals. To further test this hypothesis, the effects of insulin treatment and acute food restriction on the ability of insulin to regulate the ATPase activity in kidney basolateral membranes (BLM) of NIDD rats were studied. Although insulin levels in NIDD and control rats were similar, plasma glucose was higher in the NIDD rats (18.3 ± 1.5 v 19.3 ± 1.7 μU/mL and 236 ± 32 v 145 ± 3 mg/dL, respectively). Insulin treatment (2 U100 g), which increased plasma insulin in the NIDD rats (47.8 ± 11.5 μU/mL; P < .05), did not decrease their glucose (221 ± 25 mg/dL). Higher insulin dose (4 U100 g) decreased glucose level in the NIDD rats (73 ± 3 mg/dL; P < .001) but increased their plasma insulin 10-fold (202.5 ± 52.5 μU/mL). Acute food restriction decreased glucose levels in the NIDD rats to levels seen in controls (135 ± 3 mg/dL), while their insulin decreased by half (8.5 ± 1.0 μU/mL; P < .05). Basal (Ca2+ + Mg2+)-ATPase activity in BLM of all diabetic rats was higher than in controls (P < .05). None of the treatments reversed this defect. Insulin (12.5 to 200 μU/mL) increased the ATPase activity (10% to 40%) in BLM from controls but not from NIDD rats. In BLM from food-restricted diabetic rats, insulin increased the enzyme activity by 16% to 42%, but the dose-response curve was shifted to the right. In BLM from insulin-treated rats, insulin caused a slight (10% to 20%) increase in enzyme activity only at its highest concentration (200 μU/mL). These findings confirm the existence of insulin resistance in the NIDD rats and reveal that acute food restriction ameliorates it. The amelioration of insulin resistance was accompanied by a regained ability of insulin to regulate the membrane (Ca2+ + Mg2+)-ATPase. It is suggested that part of the beneficial effect of food restriction on insulin resistance in the NIDD rat is due to a restoration of insulin's ability to regulate cell Ca2+ homeostasis.

Diabetes affects about 7% of the US population with more than 90% of cases being type 2 diabetes mellitus. In 2005, this translated into nearly 21 million Americans with diabetes. Whereas Americans from all ethnic and cultural groups are affected, minority populations are disproportionately affected. In fact, diabetes prevalence is 2 to 6 times higher among Latino Americans, African Americans, Native Americans (American Indians and Native Alaskans), and Asian Americans than among white Americans. The National Institutes of Health reports that American Indians and Native Alaskans are 2.2 times more likely to have the disease than are non-Hispanic whites. Furthermore, studies using glycosylated hemoglobin (A1C) as a marker have shown that Latino Americans, African Americans, and Asian Americans have poorer control of their diabetes. In a study by Brown and colleagues, mean A1C levels were higher among Latino Americans, African Americans, and Asian Americans/Pacific Islanders than among white Americans.

For decades, it has been assumed that the nature and art of medicine automatically embrace an unbiased approach to maintaining health and life. Current data show this is not the case. An estimated 3.2 million African Americans--comprising 13.3% of the African American population in the United States--aged 20 years and older currently have type 2 diabetes mellitus (T2DM). Among this group, a third are undiagnosed. To start addressing the "why and how," we must examine and address the underlying problem of disconnection. This is a repurposed word used to introduce the concept of "barrier." As it relates to the African American patient and T2DM, a disconnection exists on several levels, including health beliefs, nutritional practices, religious beliefs and practices, interactions with the health care system, and socioeconomic issues. Being aware of these factors and being prepared to assess and treat the African American patient with respect and compassion is the best way to make a positive impact on the devastating epidemic of T2DM.

African Americans have higher rates of cardiovascular disease (CVD) than do Caucasians, which contributes significantly to their reduced life expectancy. Most African American adults have at least one major risk factor for CVD. Nonetheless, African Americans are often underdiagnosed and undertreated, despite presenting to the healthcare system late in their course, often after a CVD event. Patients with multiple risk factors have a CVD risk far greater than the sum of their individual risks. Metabolic syndrome tends to be clustered to a greater degree in African American women. Aggressive management of African Americans is necessary. In this report, we provide guidelines for the management of high-risk African Americans. For each individual risk factor, we address existing data and guidelines in the general population, existing data in African Americans, and proposed guidelines for African Americans based on evidence or extrapolation. In particular, for elevated cholesterol and blood pressure, evidence is emerging that lower is better, so aggressive management strategies are necessary. For dyslipidemia, statins alone will generally reach the goal, but for hypertension, multiple drugs are usually necessary. We conclude that further research in African Americans is necessary to complete the totality of evidence.

Background Studies derived from continuous national surveys have shown that the prevalence of diagnosed diabetes mellitus in the US is increasing. This study estimated the prevalence in 2004 of self-reported diagnosis of diabetes and other conditions in a community-based population, using data from the Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD). Methods The initial screening questionnaire was mailed in 2004 to a stratified random sample of 200,000 households in the US, to identify individuals, age ≥ 18 years of age, with diabetes or risk factors associated with diabetes. Follow-up disease impact questionnaires were then mailed to a representative, stratified random sample of individuals (n = 22,001) in each subgroup of interest (those with diabetes or different numbers of risk factors for diabetes). Estimated national prevalence of diabetes and other conditions was calculated, and compared to prevalence estimates from the National Health and Nutrition Examination Survey (NHANES) 1999–2002. Results Response rates were 63.7% for the screening, and 71.8% for the follow-up baseline survey. The SHIELD screening survey found overall prevalence of self-reported diagnosis of diabetes (either type 1 or type 2) was 8.2%, with increased prevalence with increasing age and decreasing income. In logistic regression modeling, individuals were more likely to be diagnosed with type 2 diabetes if they had abdominal obesity (odds ratio [OR] = 3.50; p < 0.0001), BMI ≥28 kg/m2 (OR = 4.04; p < 0.0001), or had been diagnosed with dyslipidemia (OR = 3.95; p < 0.0001), hypertension (OR = 4.82; p < 0.0001), or with cardiovascular disease (OR = 3.38; p < 0.0001). Conclusion The SHIELD design allowed for a very large, community-based sample with broad demographic representation of the population of interest. When comparing results from the SHIELD screening survey (self-report only) to those from NHANES 1999–2002 (self-report, clinical and laboratory evaluations), the prevalence of diabetes was similar. SHIELD allows the identification of respondents with and without a current diagnosis of the illness of interest, and potential longitudinal evaluation of risk factors for future diagnosis of that illness.

Coronary heart disease (CHD) is the second leading cause of death in the United States. Despite previous downward trends, which have not persisted, CHD mortality remains higher in African Americans than in Whites. Among African American and White adolescents and adults are trends of increased physical inactivity, smoking, and obesity. Approximately 47 million Americans have metabolic syndrome, a constellation of obesity, hypertension, dyslipidemia, and insulin resistance leading to diabetes. Despite a lower prevalence of metabolic syndrome, African Americans are more insulin resistant than Whites at similar degrees of adiposity, have higher blood pressures, and among women, have more obesity. Since African Americans tend to be diagnosed later and have more risk factors, which confers greater than additive risks, we propose the term "African American multiple-risk patient (AAMRP)." The AAMRP poses clinical and public health challenges for healthcare providers. We provide clinical and public health strategies for early detection and aggressive management of AAMRP.