Jay H. Shubrook, DO; James J. Chamberlain, MD


April 23, 2018

Jay H. Shubrook, DO: Hi. This is Jay Shubrook, professor and diabetologist at Touro University in California. Today's discussion continues our series, Everyday Diabetes: Practical Management for Primary Care.

I am delighted to have Dr Jim Chamberlain with me. Jim is medical director for diabetes services at St Mark's Hospital and St Mark's Diabetes Center in Salt Lake City, Utah. He is also an active member of the Primary Care Advisory Group of the American Diabetes Association. We have a very important topic to discuss. A study in Diabetologia[1] that looked at the age of diagnosis and the severity of the type 2 diabetes found that the younger you are at diagnosis, the worse the disease. Tell me more about that.

James J. Chamberlain, MD: We have a lot to talk about. We are used to seeing the type 2 diabetes and obesity epidemic in adults. But during the past couple of decades, we have started to see this in kids, teenagers, much younger adults—people much younger than we have been used to diagnosing with diabetes.

We have long assumed that living more years with obesity and diabetes, and all the things that go along with that, is not good. But this new study is quite eye-opening and scary. It showed that for every decade you live with diabetes, your life expectancy drops significantly. For example, let's look at two 50-year-old men, one who was diagnosed with type 2 diabetes a year ago, the other who was diagnosed 11 years ago. At this same point in time, the man who was diagnosed 11 years ago has about a 30% higher risk of dying and a 60% increased risk of cardiovascular mortality than the man who was diagnosed 1 year ago. Cardiovascular death is driving this elevated risk. That is a huge risk and we must figure out how to address it.

Shubrook: That is extremely important. We always think about the microvascular complications of diabetes, but it is heart disease and stroke that kills most people with diabetes, as was seen in this study. I know that younger age at diagnosis is worse, but younger people are also developing complications sooner than older people who have had diabetes for the same duration.

Chamberlain: Yes, and that is something we don't understand. This study was quite well done and well reported. The investigators cite another study that found that if you are diagnosed with type 2 diabetes before age 45, you have a 14-fold higher risk of having a myocardial infarction compared with someone your age who does not have diabetes.[2] That is incredible.

We need to learn more about the phenotype of these people who are diagnosed with diabetes at a younger age. There is something different about them. Many of these people have very aggressive cardiovascular risk factors. They have hypertension that is hard to treat. They have the typical dyslipidemia of diabetes, but sometimes it is even worse, with very high triglycerides; low high-density lipoprotein cholesterol (HDL-C); and perhaps more of the small, dense, atherogenic, "bad" low-density lipoprotein cholesterol (LDL-C). We do not know. There is something different in people who get type 2 diabetes at age 30 versus age 60. We have to get better at treating those people and their diabetes.

Why Are Younger Patients Developing Diabetes?

Shubrook: Why do you think we are seeing more and more younger people with diabetes? Twenty years ago, it was very uncommon for me to see a 30-year-old with type 2 diabetes.

Chamberlain: I believe it is our society, Jay. We have been talking about this for a long time. Too many calories in, not enough calories out. Cheap calories from highly processed foods are everywhere. Too many people are sedentary. How do we get people moving? With all of our technology, it is very easy not to move much these days. This is a worldwide health crisis. You could argue that obesity and the diseases stemming from obesity are the single biggest health crisis in this world: diabetes, cancers, sleep apnea, vascular endothelial effects, vascular disease. This is a huge problem.

We must get people moving. We have to get people to control calories and to try to maintain healthy weights. We are beginning to make progress. We are starting to see the obesity rates slow down, at least in America. They are not rising exponentially as they have been for a long time. People are more aware now. But we as physicians have to help our patients understand the importance of weight control and all of the bad things resulting from obesity.

Shubrook: Something that's near and dear to my heart is the National Diabetes Prevention Program. This program has been shown to prevent, or at least delay, the onset of type 2 diabetes in people at risk. What is your take on this? I don't believe that everyone who participates in that program will have a life without diabetes, but is it a reasonable approach to delay the diagnosis of diabetes?

Chamberlain: Ten or 15 years ago, we used the term "Syndrome X." It really just meant metabolic syndrome. It meant that people develop obesity, central adiposity, which leads to hypertension, dyslipidemia, insulin resistance, prediabetes, and all of that. As you said, the Diabetes Prevention Program works. Intensive lifestyle intervention results in a 60% reduction in your risk of going from prediabetes to diabetes.[3] Metformin was half as good. Let's do both. And let's identify people early. We have to keep looking out for them.

Maybe we should start using the term Syndrome X again and focusing on people who are developing prediabetic A1c and blood sugar levels, high triglycerides, low HDL-C, hypertension or prehypertension, and obesity. We should get on those people and point them to the resources we know make a difference: diabetes education, diabetes prevention–type programs, using drugs like metformin to keep blood sugar controlled. We have to be aggressive with hypertension and lipid management, too.

Shubrook: What I heard you saying is that we should not be complacent when younger people get type 2 diabetes. We can make a difference by being more aggressive with their screening and treatment. We should probably be more aggressive with the diagnosis and with our interventions. The younger age alone bodes a worse outcome if we do nothing.

Chamberlain: Absolutely. This study included three quarters of a million people in Australia and millions of patient-years. These are real data. I don't know how you could look at that study and not understand that we have to be aggressive. This is not the time to back off on diabetes management. It is the time to get aggressive, especially with younger people. They have a long time to live. These data show that the risk of dying and of cardiovascular death is increased dramatically the earlier you are diagnosed with type 2 diabetes.

When we catch it early, we should institute aggressive early management with glucose control, hypertension and lipid control, lifestyle interventions, diabetes education, weight loss, exercise, getting down to healthy weights—we must be aggressive. This is scary stuff. This is the time to move; it is not the time to back off.

Shubrook: Thank you so much. I appreciate your insights and I always appreciate your contributions to Everyday Diabetes: Practical Management for Primary Care.


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