Dr Esther Briganti
MBBS MClinEpi PhD FRACP
Adjunct Associate Professor, Monash University Faculty of Medicine, Nursing and Health Sciences (Eastern Health Clinical School)
Diabetes is a complex and chronic condition, contributing to significant physical and psychological morbidity. The most recent estimates of the burden of diabetes in Australia are from the Australian Health Survey, which was undertaken by the Australian Bureau of Statistics from 2011 to 2012, and the prevalence of diabetes was estimated to be approximately one million people.
It has been predicted that if the prevalence continues to rise at the current rates, by 2025 up to three million Australians will have diabetes. The majority of this increase in prevalence of diabetes is due to type 2 diabetes in adults, driven predominantly by the increasing problem of obesity and the ageing population. However, an increasing incidence of type 2 diabetes in children and teenagers, and increasing incidence of type 1 diabetes in children have also been noted.
There is also an increasing recognition that the spectrum of diabetes-related complications extends beyond the classic acute metabolic and chronic vascular and neuropathic complications. In people with type 2 diabetes this includes various cancers, dementia, fractures, liver disease, heart failure, hearing loss, periodontal disease and depression. For those with type 1 diabetes there are increased rates of autoimmune endocrinopathy, in particular thyroid disease and coeliac disease, as well as other autoimmune conditions.
This all contributes significantly to the physical, emotional and financial burden of diabetes, and notably increases the complexity of care and need for multidisciplinary health-care involvement. The current paradigm of diabetes care is centred on the prevention, detection and treatment of complications associated with diabetes. This ideally requires intensive involvement of patients themselves, as well as a wide variety of health-care professionals, and therefore is associated with high direct and indirect health-care costs.
With the predicted increase in diabetes prevalence and therefore burden of diabetes complications, there is an urgent imperative to shift the focus of attention and efforts to the prevention of type 2 diabetes, as well as more aggressive management strategies earlier in the natural history of type 2 diabetes. Both strategies are supported by evidence from clinical trials.
There are immediate opportunities for a significant impact in the prevention of type 2 diabetes by targeting the major risk factors of obesity and prediabetes. The benefit of lifestyle intervention with associated weight loss has been shown in a number of studies, of which the two largest were the United States Diabetes Prevention Program and the Finnish Diabetes Prevention Study. Intervention has the potential to more than halve the incidence of type 2 diabetes. Studies in Asian populations have shown similar benefits.
Several drugs that are used in the treatment of type 2 diabetes have also been shown to prevent progression of prediabetes to type 2 diabetes. These include liraglutide, pioglitazone, acarbose and in particular, metformin, which has been shown to be effective in reducing the risk of type 2 diabetes in a number of clinical trials, particularly in those at highest risk of progression.
Observational studies have also shown bariatric surgery to be effective in the prevention of type 2 diabetes in obese persons. Findings from many of the clinical trials of pharmacotherapy and lifestyle intervention in type 2 diabetes seeking to reduce cardiovascular morbidity and mortality consistently indicate that the most convincing benefit is in the early phase of the natural history of type 2 diabetes.
Efficient, cost-effective, acceptable
In terms of diabetes complications, more innovative models of care are needed to deliver the wide scope of proven effective therapies in ways that are efficient and cost-effective, and acceptable to people with diabetes to ensure adherence. This is particularly pertinent in light of the expanding spectrum of recognised diabetes related complications, and the already wide treatment gap that continues to be shown to exist when the quality of current diabetes care is measured against recommended treatment guidelines.
Further challenges lie in reducing the inequities in diabetes service provision, in particular for Indigenous Australians and other disadvantaged groups. The evidence base for structured self-management education interventions is encouraging, with the application of self-management strategies having been shown to be associated with improvements in health outcomes in diabetes.
Innovative technological advances ranging from developments in drugs, drug delivery devises, monitoring systems and systems of health-care delivery, including the greater use of telemedicine, also offer hope of improved health outcomes and quality of life. However, the effective translation of these advances into clinical practice can be costly and require substantial time for appropriate engagement, education and interaction of patients, families and health-care professionals to ensure the optimum use of these technological advances.
There are many challenges in refocusing clinical attention on the prevention of type 2 diabetes, as well as the development and implementation of innovative effective models of care in relation to diabetes related complications. The imperative for this is fast becoming more important than ever.