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Diabetes Mellitus Type 2Published by: Domus Medica | SSMGLast published: 2017Diabète sucré de type 2Published by: SSMG | Domus MedicaLast published: 2017

Although the life expectancy of those with type 2 diabetes is improving in many high-income countries, the burden of the disease remains high, and,​ despite the existence of effective treatments, many people do not meet recommended glycemic targets.[399][400]​ Even in high-performing health care systems, 10% to 15% of people with type 2 diabetes maintain an hemoglobin A1c (HbA1c) >8.5% despite receiving available diabetes care.[400]​ Factors leading to suboptimal glycemic management include therapeutic inertia, inconsistent drug use, and limited participation in diabetes education programs. These issues are compounded by access barriers like location and cost.[400]​ The persistence of racial and ethnic disparities highlights the emergent need for equitable diabetes care that addresses social determinants of health.[400]

Diabetes increases the likelihood of major cardiovascular (CV) events and death. This increased risk is variable across patient groups, depending on age at diabetes onset, duration of diabetes, glucose control, blood pressure control, lipid control, smoking status, renal function, microvascular complication status, and other factors. The association of diabetes and increased mortality can be attenuated by optimizing the management of hyperglycemia and CV risk factors.[401] While an HbA1c of 6% to 6.9% (42-52 mmol/mol) correlates with the lowest mortality, evidence is limited regarding the benefits of tight glycemic control in older individuals, with some data suggesting that it may in fact be associated with higher mortality in this population.[35]​[401]​​

Trends in data for complications in people with diabetes show a declining risk of cardiovascular disease (CVD) and CVD-associated mortality, particularly in high-income countries, coinciding with markedly increased use of prophylactic CV drugs.[28][402]​​​​​​ However, CVD is still the leading cause of death in people with diabetes.[403] ​While the benefits of optimizing CVD risk factors are clear, in practice many patients are not achieving recommended targets.[404][405]​​ Data from the US Diabetes Collaborative Registry of 74,393 adults with diabetes demonstrate a prevalence of 74% with HbA1c <7%, 40% with blood pressure <130/80 mmHg, and 49% with low density lipoprotein-cholesterol <100 mg/dL (<70 mg/dL if with atherosclerotic CVD), but only 15% at target for all 3 factors.[406] Newer evidence-based therapies for diabetes proven to reduce CVD risk, including sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists, remain highly underused.​[407]

When type 2 diabetes is diagnosed at age 40, men lose an average of 5.8 years of life, and women lose an average of 6.8 years of life.[34] The overall excess mortality in those with type 2 diabetes is around 15%, although this risk ranges dramatically depending on patient characteristics.[17]​​​ Excess mortality is substantially higher with worsening glycemic control, impaired renal function, and younger age.[17]​ One large observational study found that every decade of earlier diagnosis of diabetes is associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes.[408]

Cumulative prevalence of vision-threatening diabetic retinopathy in the US is about 4.4% among adults with type 2 diabetes, and appears to be higher for non-Latino black people compared with non-Latino white people (9.3% vs. 3.2%, respectively).[409]

Prevalence of end-stage renal disease (ESRD) is about 1% in those with type 2 diabetes (cross-sectional data), but cumulative prevalence of nephropathy and/or chronic kidney disease is much higher.[410] Incidence rates of ESRD attributed to diabetes are declining; however, continued intervention to detect and manage diabetic kidney disease is required to limit the development of ESRD.[411] Rates of ESRD are higher in older adults in comparison to younger adults.[35]​

Older adults with type 2 diabetes are more likely to have other age-related conditions, including cognitive dysfunction, depression, frailty and sarcopenia, and incontinence, all significantly impacting quality of life.[35] They are also more likely to experience polypharmacy.[35] Effective treatment requires a motivated and informed patient who actively takes responsibility for the care of his or her diabetes, and a healthcare provider team willing to frequently adjust drug treatment to support comprehensive disease management over a long period of time.

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