**Principle of Management of Type 2 Diabetes: From Clinical, Public Health and Research Perspectives Clinical, Public Health and Research Perspectives**

**Principle of Management of Type 2 Diabetes: From** 

DOI: 10.5772/intechopen.71193

Madhur Dev Bhattarai Additional information is available at the end of the chapter

Madhur Dev Bhattarai

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176 Diabetes and Its Complications

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.71193

#### **Abstract**

Apart from stopping smoking, controlling hypertension and using statin, losing possible excess bodyweight and regular physical activity and exercise are the cornerstones in diabetes management. There is often need of controlling blood glucose immediately. Approach of '*dynamic dose management of medications likely to cause hypoglycemia*' helps to control high blood glucose immediately as and when required with sulfonylurea or insulin and to taper off their dose later. Anti-hyperglycemic medications which are unlikely to cause hypoglycemia are continued to control hyperglycemia. The diagnosis of gestational diabetes usually made at 24-28 weeks is applicable for clinical management of mother and child and for possible prevention of diabetes later in the mother. From the public health perspectives, however, protection of the susceptible *in utero* population from maternal malnutrition or clinical or subclinical hyperglycemia right from the time of conception itself also needs to be considered to control the diabetes epidemic at the population level. Campaigns and programmes for maintenance of optimal pre-pregnancy body weight as per the recommended body mass index of the respective populations along with regular physical activity and exercise during pregnancy are the essential measures available at hand to prevent the possibility of maternal hyperglycemia right from the early pregnancy.

**Keywords:** diabetes, CVD, hypertension, high blood pressure, physical activity, exercise, smoking, body mass index, ethnicity, hypoglycemia, acarbose, diabetes epidemiology, diabetes control, maternal health, pre-pregnancy weight

#### **1. Introduction**

There are now estimated 415 million adults aged 20–79 with diabetes worldwide and a further 318 million adults are estimated to have impaired glucose tolerance [1]. About half of the

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3.7 million deaths due to diabetes and its complications occur before the age of 70 years [2]. Up to 80% of deaths in type 2 diabetes are cardiovascular diseases (CVDs) related. Persons with impaired glucose tolerance are also almost three times more likely to develop coronary heart disease and other major cardiovascular events than people with normal glucose tolerance. In fact, CVDs alone account for nearly 30% of all deaths worldwide and 27% in lowincome and middle-income countries [3, 4]. Thus, in one hand, there is a need to prevent and treat diabetes, and on the other hand, considering various possible risk factors, the impaired glucose tolerance itself and CVDs have to be prevented both at individual and population levels.

> BP) is considered as one of the ideal health factors for cardiovascular health [7, 8]. Programmes for controlling high BP in the industrialized countries achieved significant reduction in CVD mortality [7], and tobacco smoking including the second-hand smoke became the leading risk factor [13]. In many non-industrialized countries, such programmes have mostly not been accomplished. As a matter of fact in many such countries due to the inadequate network of the State supported rural and urban health centers/clinics, people often have limited access to blood pressure monitoring and management [15]. It is difficult for the people to regularly visit private clinics or to wait at the long queue in the free medical clinics of public hospitals. In such situations, the patients are more likely to visit hospitals late for crisis management only when the complications (like stroke, coronary heart diseases, kidney failure or pneumonia)

Atherosclerotic cardiovascular disease Unhealthy diet Overweight/obesity

Tobacco use Physical

inactivity

Principle of Management of Type 2 Diabetes: From Clinical, Public Health…

Dyslipidemia

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Death rate due to CVD, even in the industrialized countries, seems to be on increase again particularly in the relatively younger population [8]. The emerging epidemic of glucose intolerance, another CVD risk factor, seems to be adding up and interplaying with high BP. Among more than 3000 Euro Heart Survey patients with acute and elective coronary heart diseases, only about one-fourth had normal plasma glucose by the WHO criteria [16]. If the American Diabetes Association classification with fasting plasma glucose >5.6 mmol/L (>100 mg/Dl) had also been considered, the proportion of patients with glucose intolerance would perhaps have been more, as reported in another study in patients with acute coronary insufficiency [17]. There are two pertinent points to note in the interaction between high BP and glucose

Firstly, hypertension is relatively more common in people with diabetes, about two times more in one study [18], than in those with normal plasma glucose. More than 75% of adults with diabetes have blood pressure (BP) levels ≥130⁄80 mmHg or are using antihypertensive medication [12]. Secondly, the adverse effects of higher blood pressure are more in people with glucose intolerance than in those with normal blood glucose. Even among people with systolic BP between 120 and 139 mmHg (i.e. at pre-hypertension level), CV mortality rate is about three times more in those with diabetes than in those without diabetes. And the risk is similarly high in different systolic BP ranges from normal to high levels [19]. Mortality is indeed increased 7.2-fold when hypertension is present in patients with diabetes [12]. Lowering 4 mmHg of systolic BP is more effective in reducing cardiovascular events than

**2.2. Interaction of high blood pressure and glucose intolerance**

develop [15].

High blood pressure

Glucose intolerance

**Figure 1.** The seven modifiable risk factors of atherosclerotic cardiovascular disease.

intolerance.

This chapter will focus on the principles of management of type 2 diabetes at individual and population levels to consider while following the guidelines and managing diabetes and its epidemic. Management is defined as the act or skill of dealing with people or situations in a successful way [5]. The term management in the chapter covers clinical management, research and public health perspectives. Public health is the practice of preventing disease and promoting good health within groups of people, from small communities to entire countries [6]. Primary prevention requires a focus on individuals known to be at risk for disease, i.e. the high-risk strategy with interventions focused on high-risk group, for example on people with glucose intolerance. A large proportion of the reductions in coronary heart disease mortality experienced in many high-income nations since the 1960s have been ascribed to the interventions in people at elevated risk [7]. However, individuals with markedly elevated levels of risk factors are relatively uncommon in the population. The majority of CVD events occur in individuals with average or only mildly adverse levels of risk factors [7, 8]. Therefore, population-wide strategies are also essential. Health promotion and disease prevention strategies must embrace both high-risk and population strategies [7–10].
