Poor diabetes control increases the risk of developing cardiovascular disease within a period of 10-20 years and contributes to lower life expectancy.

In recent years, much younger individuals have been developing type 2 diabetes mellitus, due mainly to increased levels of obesity and excess weight in childhood.

An integrated approach, personalized treatment, improved adherence, and patient education are the major goals of diabetes treatment, according to more than 450 experts in the field who attended the Madrid meeting.

Therapeutic compliance in type 2 diabetes mellitus (DM2) is crucial. However, only 30%-50% of patients receiving oral antidiabetics, and not even 25% of those receiving insulin adhere to their treatment regimen1. The worst compliers are younger patients who, moreover, are at greater risk of developing cardiovascular complications. This was the claim of the specialists who attended Diabento, a symposium of more than 450 physicians from all around Spain who analyzed current and future challenges in DM2 from a multidisciplinary perspective.

The symposium, organized by ESTEVE, was accredited and supported by the major scientific societies: the Spanish Society of Family and Community Medicine (semFYC), the Network for the Study of Diabetes in Primary Health Care (redGDPS), the Spanish Society of Endocrinology and Nutrition (SEEN), the Spanish Society of Internal Medicine (SEMI), and the Spanish Society of Primary Care Physicians (SEMERGEN).

Lack of compliance is one of the major causes of poor metabolic control and is associated with greater cardiovascular morbidity and mortality in DM2. "Younger patients are the ones with the poorest disease control. We must focus on the care of diabetics between 40 and 50 years of age, because these patients will have DM2 for many more years and will be exposed to a greater risk and earlier onset of chronic complications derived from diabetes, particularly cardiovascular issues" said Dr. Edelmiro Menéndez, chairperson of the Spanish Diabetes Society and scientific coordinator of Diabento.

Patient education in disease control is essential. DM2 treatment is lifelong, and as well as adhering to their pharmacological treatment, patients must be prepared to make lifestyle changes. An integrated approach must be taken, taking into account all cardiovascular risk factors, and treatment must be personalized according the characteristics and clinical history of each patient. "DM2 patients in general have more than one disease, so concomitant conditions must also be considered, and the drugs we use can have very different mechanisms of action that are sometimes complementary. Guidelines are useful, but only to a certain extent, because the recommendations are general, but treatment must be as individualized as possible."

In Spain, the Ministry of Health initiated a National Diabetes Plan, one of the objectives of which was to improve treatment compliance in DM2, but according to Dr. Menéndez, "due to the transfer of responsibilities to the autonomous communities, the implementation of these guidelines cannot be followed up".

DM2: onset occurs much earlier, due to increasing obesity

Diabetes affects almost 5 million Spaniards, of whom 1.5 million are undiagnosed, according to data from the Di@betes study2. The latest epidemiological studies show that prevalence is growing: currently there are almost 400 million diabetics worldwide, a figure which is forecast to increase to almost 600 million by 2035, representing a growth of almost 50% in 20 years.

"In a period of 10-15 years, we have seen DM2 appearing at ever earlier ages, particularly in patients aged around 30, something which never happened before", said Dr. Menéndez. This enormous increase in the prevalence of DM2, particularly among younger individuals, is directly related with increasing levels of obesity and excess weight. "There is a pathogenic relationship between obesity and the development of insulin resistance that leads to the appearance of type 2 diabetes. This is what we have to prevent".

Currently, Spain is the country with the highest rate of childhood obesity in the European Union. Moreover, Dr Menéndez added, "80% of DM2 patients are obese and the rest are overweight. Less than 10% are of normal weight".

Diabetes and cardiovascular risk: the vicious circle

Poorly controlled DM2 is a risk factor for cardiovascular complications. In fact, the main cause of death in these patients is cardiovascular disease, which causes 86% of deaths and 75% of hospitalizations1. DM2, in turn, is in itself, a risk factor for the appearance, development and poor prognosis of ischemic heart disease and heart failure. For this reason, "the integrated treatment of DM2 must focus not only on blood glucose control, but also on lipids, blood pressure, and other risk factors, to reduce the chances of microvascular and macrovascular complications".

The experts highlighted the appearance in recent years of new drugs for the treatment of DM2, such as sodium-glucose co-transporter 2 (SGLT2) inhibitors, which, in addition to reducing blood glucose levels, act on other factors for cardiovascular risk.

Another common complication of DM2 is diabetic nephropathy. "In Spain, almost half of all patients receiving renal replacement therapy are diabetics. And this situation is the result of poor DM2 control".

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