Future Research Directions
The convergence of pathways underlying diabetes and CVD on inflammation and oxidative stress suggests that these age-related diseases might arise from a common foundation. An overarching research question then is how various mechanisms contributing to diabetes and CVD affect and are affected by advancing age. Many other potential research directions, including specific questions listed in Table 3, also should be explored. In the past, research has often examined pathways, organs, and systems independently. However, optimal health relies on a balance of interrelated systems, and age or diabetes may shift that balance. The mechanisms underlying the cardiovascular, renal, nerve, and cognitive complications of diabetes suggest a common microvascular pathway. More research is needed on interactions between vascular and cognitive abnormalities and on signaling between the cardiovascular system and the brain. Increased understanding of the pathways common to diabetes, CVD, and other morbidities might yield optimal treatments for diabetes and its complications. More multidisciplinary or interdisciplinary studies are needed.
Animal models of aging are needed to explore many of these questions, keeping in mind that differences between organisms can hamper the translation of observations. Likewise, clinical trial populations are highly selected and have largely excluded older individuals with diabetes so that results are not generalizable to patients in everyday practice. Improved predictive models, including those that account for patient heterogeneity and can be used in real practice, are needed for clinical trial participant selection. Finally, intervention development has suffered because epidemiologically powerful associations have not necessarily been borne out in intervention trials. While clinical end points and mortality remain important, future studies also should include end points, such as functional outcomes, that are of particular interest to older adults. Thus, geriatricians should be involved in clinical trial design and in achieving consensus on the best measures and scales for assessment.
The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of National Institute on Aging or the National Institutes of Health. In addition, the views expressed in written conference materials or publications and by speakers or moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention by trade names, commercial practices, or organizations imply endorsement by the U.S. government.
The authors are grateful to Nancy Woolard at Wake Forest School of Medicine for her assistance with organizing the workshop. To see the agenda, a list of workshop moderators and attendees, and workshop presentations, please visit https://www.im.org/AcademicAffairs/Aging/IGP/ExpandingResearchEfforts/Pages/ASPWorkshoponDiabetesMellitus%20and%20CardiovascularDiseaseinOlderAdults.aspx. The authors recognize early leaders who linked diabetes, CVD, and aging, including W.R.H. and Daniel Porte Jr., who also was a workshop attendee and active contributor to the discussion there. The authors also acknowledge the contributions from planning committee members who reported conflicts of interest with authorship of this Perspective: Basil Eldadah, Judith Fradkin, and K. Sreekumaran Nair.
This workshop was supported by generous grants to Association of Specialty Professors from the National Institute on Aging (1-U13-AG-040938 01) and the John A. Hartford Foundation (J.B.H., K.E.S., K.P.H.). J.B.H. reports grants from the John A. Hartford Foundation, National Institutes of Health's National Institute on Aging, and Alliance for Academic Internal Medicine during the conduct of the project, and from the American Diabetes Association outside the submitted work. F.M.H. reports grants from the John A. Hartford Foundation during the conduct of the project.
Duality of Interest
J.B.H. reports grants from Janssen Pharmaceuticals, Takeda Global Research and Development, Sanofi, and Boehringer Ingelheim outside the submitted work. L.H. reports relationships or activities with Spiracur, Organogenesis, Anacor, and Valient. M.S.K. reports grants from Novo Nordisk outside the submitted work. J.P. reports personal fees from Janssen Pharmaceuticals, Novo Nordisk, Bristol-Myers Squibb, AstraZeneca, and Roche/Genentech outside the submitted work; all work is related to consulting. S.Z. is a U.S. government employee. No other potential conflicts of interest relevant to this article were reported.
J.B.H. and N.M. were coleaders of the workshop and led the planning committee activities, served as presenters and moderators, and played leading roles in the review and editing of the manuscript. F.M.H. wrote the initial draft of the manuscript, based on the material presented at the workshop. J.P.C., A.G., L.H., W.R.H., E.S.H., M.S.K., J.P., and S.Z. were members of the planning committee, which organized the workshop, served as presenters or moderators, and reviewed and edited the manuscript. K.E.S. and K.P.H. helped to organize and moderate the workshop and reviewed and edited the manuscript.
Diabetes. 2014;63(8):2578-2589. © 2014 American Diabetes Association, Inc.