Diabetes is Increasing in Prevalence
Barry J. Goldlist, MD, FRCPC, FACP
Our theme for this first issue of the new millennium is diabetes mellitus in the elderly. It is an appropriate topic because there are two main factors driving the increase in the numbers of patients with diabetes; these are the aging of the population, and the increasing prevalence of obesity. Unfortunately, particularly in the 'young old' these two factors frequently coexist.
Diabetes, like many other chronic disorders, results from a combination of both genetic and environmental factors. The major environmental factor is the increasing obesity of our population, but the genesis of that obesity is very complex. Two of the factors involved are changing dietary patterns and decreased physical activity. As in most diseases, prevention is the most effective treatment. However, improving eating habits and increasing physical activity is not easy to achieve in large populations, particularly when cars and fast foods are omnipresent.
Diabetes mellitus is a major risk factor for renal failure and vascular disease in the elderly; yet, despite much evidence to the contrary, physicians are often hesitant to aggressively treat this population. At times, this might be the correct course, but often the hesitancy is based on misconceptions concerning life expectancy at various ages. A healthy 70-year-old woman has a life expectancy of about 17 years, or more than 20% of her entire life! Even at age 80, a healthy woman has 7-8 years of life expectancy ahead, or 10% of her life. These are substantial periods of time, and suggest that treatment to prevent further complications of diabetes is very well warranted. In fact, the same holistic approach to diabetes management that is used in younger patients is appropriate for many older diabetics, particularly that group of 'young old' aged 65-75.
This holistic approach includes paying detailed attention to all known risk factors. There is excellent evidence that effective blood pressure control, lowering lipids, and the appropriate use of ACE inhibitors and beta-blockers, is effective for reducing cardiovascular risk in patients with diabetes. Tight glucose control, lowering triglycerides, and increasing HDL are more controversial strategies to prevent complications in elderly patients with diabetes. Of course, early attention to any complications (e.g. foot care, eye care) is also critical in maintaining quality of life.
This edition will address some of the acute complications of diabetes (by Daniel Tessier), foot care (Leslie Goldenberg) and diabetic retinopathy (Mark Mandelcorn). The most important issue for many elderly patients is learning about the disease and its dietary control, and Tess Montada-Atin has written an excellent article on this topic. As well as our usual pot pourri of columns, there are articles on peripheral vascular disease in the elderly, recent developments in the primary care of dementia (Serge Gauthier), the difficulties in prescribing for older people, and an article on ethics. Fittingly, for this edition, our article on the biology of aging is focussed on mechanisms of insulin resistance.
I hope you enjoy this edition.