Current state of affairs and future directions

Although the wisdom of addressing multiple risk factors seems to be intuitively obvious, this approach is not what transpires in practice. Data from National Health and Nutrition Enhancement Survey 1999-2000 reveal that only 37% of adults with diagnosed diabetes in the United States are achieving the ADA goal of glycosylated hemoglobin levels less than 7% [44]. In addition, 37% of adults with diagnosed diabetes have glycosylated hemoglobin levels greater than 8%. Only 36% of individuals with diabetes have achieved the current goals for blood pressure set in the JNC 7. More than half the individuals with diagnosed diabetes have cholesterol levels above

200 mg/dL. Thus, there is great room for improvement in the provision of diabetes care and education to capitalize on knowledge currently available. A systematic approach to the treatment of diabetes that addresses multiple risk factors is needed. The increased awareness of the importance of controlling risk factors for vascular disease among adults with diabetes has led to national programs such as the NCEP's campaign, ''Control of ABCs'' (in which "A" stands for HbA1c, "B" stands for blood pressure, and "C" stands for cholesterol) and the Diabetes Quality Improvement Project [45,46]. Techniques in comprehensive risk reduction could involve the use of standardized flow charts and diet and exercise protocols that could be developed at various clinic sites to expedite visits and establish a uniform standard of care. Trials are still needed to determine the intervention or combination of interventions that could provide the maximal benefits, the extent of these benefits and the most cost-effective approaches that could be applied to a wide group of patients.

The best approach for the problem of diabetes mellitus and associated CV disease is to prevent or delay the onset of diabetes mellitus. A truly comprehensive approach to reducing the risks posed by diabetes should explore the possibility of preventing or delaying the onset of diabetes. From a public health perspective, this approach, with the potential of wide application, might be the most cost effective strategy. Of course, the assumption is that prevention of diabetes will also lead to prevention of atherosclerosis, and this assumption is yet to be substantiated by prospective trials. To demonstrate this association, individuals at risk must be identified early in the course of development of the disease. For this reason the Western Working Group, NCEP, ADA, and other major groups have emphasized the importance of the metabolic syndrome as a potential prediabetic state [9,22,47]. Although data are lacking regarding the benefit of intervention in patients with the metabolic syndrome, simple measures such as weight reduction and regular activity can reduce the risk of developing diabetes mellitus and potentially reduce CV disease.

During the transition from euglycemia to overt diabetes, many patients go through a phase of impaired glucose tolerance or impaired fasting glucose, defined by an oral glucose tolerance test finding of 140 to 190 mg/dL and a fasting plasma glucose level of 110 to 125 mg/dL, respectively. As discussed in another article in this issue, substantial trial evidence shows that the onset of diabetes can be prevented or at least delayed in this cohort of individuals [48,49]. Emerging evidence suggests that prevention of diabetes can indeed be beneficial in reducing the risk of CV events. In the STOP-NIDDM trial, treatment with acarbose was associated with a 25% risk reduction in development of diabetes and resulted in significant reduction in CV events [50]. The results of the STOP-NIDDM trial are indeed interesting and provocative, but they need to be confirmed by other prospective, randomized clinical trials.

The prevention of diabetes may indeed be attractive, because the interventions needed are generally less expensive and would translate to large reductions in health care expenditure with the potential for reduction of macrovascular disease. Therefore, a comprehensive approach to the risk reduction of CV events associated with diabetes should incorporate diabetes prevention strategies, especially as a public health measure. It is worthwhile to remember the aphorism, ''an ounce of prevention is worth a pound of cure.''

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