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]Tomic D, Morton JI, Chen L, et al. Lifetime risk, life expectancy, and years of life lost to type 2 diabetes in 23 high-income jurisdictions: a multinational, population-based study. Lancet Diabetes Endocrinol. 2022 Nov;10(11):795-803.
https://pmc.ncbi.nlm.nih.gov/articles/PMC10988609
http://www.ncbi.nlm.nih.gov/pubmed/36183736?tool=bestpractice.com
[400]Green JB, Crowley MJ, Thirunavukkarasu S, et al. The final frontier in diabetes care: implementing research in real-world practice. Diabetes Care. 2024 Aug 1;47(8):1299-310.
https://diabetesjournals.org/care/article/47/8/1299/156804/The-Final-Frontier-in-Diabetes-Care-Implementing
http://www.ncbi.nlm.nih.gov/pubmed/38907682?tool=bestpractice.com
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]Green JB, Crowley MJ, Thirunavukkarasu S, et al. The final frontier in diabetes care: implementing research in real-world practice. Diabetes Care. 2024 Aug 1;47(8):1299-310.
https://diabetesjournals.org/care/article/47/8/1299/156804/The-Final-Frontier-in-Diabetes-Care-Implementing
http://www.ncbi.nlm.nih.gov/pubmed/38907682?tool=bestpractice.com
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]Green JB, Crowley MJ, Thirunavukkarasu S, et al. The final frontier in diabetes care: implementing research in real-world practice. Diabetes Care. 2024 Aug 1;47(8):1299-310.
https://diabetesjournals.org/care/article/47/8/1299/156804/The-Final-Frontier-in-Diabetes-Care-Implementing
http://www.ncbi.nlm.nih.gov/pubmed/38907682?tool=bestpractice.com
The persistence of racial and ethnic disparities highlights the emergent need for equitable diabetes care that addresses social determinants of health.[400]Green JB, Crowley MJ, Thirunavukkarasu S, et al. The final frontier in diabetes care: implementing research in real-world practice. Diabetes Care. 2024 Aug 1;47(8):1299-310.
https://diabetesjournals.org/care/article/47/8/1299/156804/The-Final-Frontier-in-Diabetes-Care-Implementing
http://www.ncbi.nlm.nih.gov/pubmed/38907682?tool=bestpractice.com
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]Raghavan S, Vassy JL, Ho YL, et al. Diabetes mellitus-related all-cause and cardiovascular mortality in a national cohort of adults. J Am Heart Assoc. 2019 Feb 19;8(4):e011295.
https://www.ahajournals.org/doi/full/10.1161/JAHA.118.011295
http://www.ncbi.nlm.nih.gov/pubmed/30776949?tool=bestpractice.com
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]Cappola AR, Auchus RJ, El-Hajj Fuleihan G, et al. Hormones and aging: an Endocrine Society scientific statement. J Clin Endocrinol Metab. 2023 Jul 14;108(8):1835-74.
https://academic.oup.com/jcem/article/108/8/1835/7192004
http://www.ncbi.nlm.nih.gov/pubmed/37326526?tool=bestpractice.com
[401]Raghavan S, Vassy JL, Ho YL, et al. Diabetes mellitus-related all-cause and cardiovascular mortality in a national cohort of adults. J Am Heart Assoc. 2019 Feb 19;8(4):e011295.
https://www.ahajournals.org/doi/full/10.1161/JAHA.118.011295
http://www.ncbi.nlm.nih.gov/pubmed/30776949?tool=bestpractice.com
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]Harding JL, Pavkov ME, Magliano DJ, et al. Global trends in diabetes complications: a review of current evidence. Diabetologia. 2019 Jan 31;62(1):3-16.
https://link.springer.com/article/10.1007/s00125-018-4711-2
http://www.ncbi.nlm.nih.gov/pubmed/30171279?tool=bestpractice.com
[402]Gyldenkerne C, Kahlert J, Olesen KKW, et al. Twenty-year temporal trends in risk of ischemic stroke in incident type 2 diabetes: a Danish population-based cohort study. Diabetes Care. 2022 Sep 1;45(9):2144-51.
https://diabetesjournals.org/care/article/45/9/2144/147286
http://www.ncbi.nlm.nih.gov/pubmed/35876649?tool=bestpractice.com
However, CVD is still the leading cause of death in people with diabetes.[403]Leon BM, Maddox TM. Diabetes and cardiovascular disease: epidemiology, biological mechanisms, treatment recommendations and future research. World J Diabetes. 2015 Oct 10;6(13):1246-58.
https://pmc.ncbi.nlm.nih.gov/articles/PMC4600176
http://www.ncbi.nlm.nih.gov/pubmed/26468341?tool=bestpractice.com
While the benefits of optimizing CVD risk factors are clear, in practice many patients are not achieving recommended targets.[404]Martín Enguix D, Hidalgo Rodríguez A, Sánchez Cambronero M, et al. Application of the individualized objectives defined by the European 2019 lipid guidelines in patients with type 2 diabetes. Clin Investig Arterioscler. 2022 Jan-Feb;34(1):19-26.
http://www.ncbi.nlm.nih.gov/pubmed/34876304?tool=bestpractice.com
[405]Bullock JE. Provider adherence to American Diabetes Association cardiovascular risk-reduction guidelines: an integrative review. J Am Assoc Nurse Pract. 2024 Jan 1;36(1):17-22.
http://www.ncbi.nlm.nih.gov/pubmed/37494065?tool=bestpractice.com
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]Tsao CW, Aday AW, Almarzooq ZI, et al. Heart disease and stroke statistics - 2023 update: a report from the American Heart Association. Circulation. 2023 Feb 21;147(8):e93-621.
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001123
http://www.ncbi.nlm.nih.gov/pubmed/36695182?tool=bestpractice.com
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]Martin SS, Aday AW, Almarzooq ZI, et al. 2024 Heart disease and stroke statistics: a report of US and global data from the American Heart Association. Circulation. 2024 Feb 20;149(8):e347-913.
https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001209
http://www.ncbi.nlm.nih.gov/pubmed/38264914?tool=bestpractice.com
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]Gregg EW, Zhuo X, Cheng YJ, et al. Trends in lifetime risk and years of life lost due to diabetes in the USA, 1985-2011: a modelling study. Lancet Diabetes Endocrinol. 2014 Nov;2(11):867-74.
http://www.ncbi.nlm.nih.gov/pubmed/25128274?tool=bestpractice.com
The overall excess mortality in those with type 2 diabetes is around 15%, although this risk ranges dramatically depending on patient characteristics.[17]Tancredi M, Rosengren A, Svensson AM, et al. Excess mortality among persons with type 2 diabetes. N Engl J Med. 2015 Oct 29;373(18):1720-32.
https://www.nejm.org/doi/full/10.1056/NEJMoa1504347
http://www.ncbi.nlm.nih.gov/pubmed/26510021?tool=bestpractice.com
Excess mortality is substantially higher with worsening glycemic control, impaired renal function, and younger age.[17]Tancredi M, Rosengren A, Svensson AM, et al. Excess mortality among persons with type 2 diabetes. N Engl J Med. 2015 Oct 29;373(18):1720-32.
https://www.nejm.org/doi/full/10.1056/NEJMoa1504347
http://www.ncbi.nlm.nih.gov/pubmed/26510021?tool=bestpractice.com
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]Emerging Risk Factors Collaboration. Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation. Lancet Diabetes Endocrinol. 2023 Oct;11(10):731-42.
https://pmc.ncbi.nlm.nih.gov/articles/PMC7615299
http://www.ncbi.nlm.nih.gov/pubmed/37708900?tool=bestpractice.com
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]Zhang X, Saaddine JB, Chou CF, et al. Prevalence of diabetic retinopathy in the United States, 2005-2008. JAMA. 2010 Aug 11;304(6):649-56.
https://jamanetwork.com/journals/jama/fullarticle/186384
http://www.ncbi.nlm.nih.gov/pubmed/20699456?tool=bestpractice.com
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]Centers for Disease Control (CDC). State-specific trends in chronic kidney failure - United States, 1990-2001. MMWR Morb Mortal Wkly Rep. 2004 Oct 8;53(39):918-20.
http://www.ncbi.nlm.nih.gov/pubmed/15470324?tool=bestpractice.com
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]Burrows NR, Hora I, Geiss LS, et al. Incidence of end-stage renal disease attributed to diabetes among persons with diagnosed diabetes - United States and Puerto Rico, 2000-2014. MMWR Morb Mortal Wkly Rep. 2017 Nov 3;66(43):1165-70.
https://www.cdc.gov/mmwr/volumes/66/wr/mm6643a2.htm
http://www.ncbi.nlm.nih.gov/pubmed/29095800?tool=bestpractice.com
Rates of ESRD are higher in older adults in comparison to younger adults.[35]Cappola AR, Auchus RJ, El-Hajj Fuleihan G, et al. Hormones and aging: an Endocrine Society scientific statement. J Clin Endocrinol Metab. 2023 Jul 14;108(8):1835-74.
https://academic.oup.com/jcem/article/108/8/1835/7192004
http://www.ncbi.nlm.nih.gov/pubmed/37326526?tool=bestpractice.com
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]Cappola AR, Auchus RJ, El-Hajj Fuleihan G, et al. Hormones and aging: an Endocrine Society scientific statement. J Clin Endocrinol Metab. 2023 Jul 14;108(8):1835-74.
https://academic.oup.com/jcem/article/108/8/1835/7192004
http://www.ncbi.nlm.nih.gov/pubmed/37326526?tool=bestpractice.com
They are also more likely to experience polypharmacy.[35]Cappola AR, Auchus RJ, El-Hajj Fuleihan G, et al. Hormones and aging: an Endocrine Society scientific statement. J Clin Endocrinol Metab. 2023 Jul 14;108(8):1835-74.
https://academic.oup.com/jcem/article/108/8/1835/7192004
http://www.ncbi.nlm.nih.gov/pubmed/37326526?tool=bestpractice.com
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.