Lifescience Promoting Association, Daikyo-cho 25-3-1004, Shinjuku-ku, Tokyo 160-0015, Japan; Asia Pacific Clinical Nutrition Society (APCNS), Department of Food Science and Nutrition, Zhejiang University, 866 Yu-Hang-Tang Road, Hangzhou 310058, ChinaChina
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A recent report from the American College of Physicians (ACP) should cause a paradigm change for the treatment of diabetic patients.1 The main purpose of diabetes therapy is the prevention of complications.2 The endpoint of many clinical trials is to lower blood glucose levels, but intensive treatments aimed at lowering the HbA1c to less than 6.5% are often accompanied by hypoglycemia as a side effect. At the same time, intensive regimens have not shown a reduction of cardiovascular complications in the longterm. 3-7 For example, the action to control cardiovascular risk in diabetes (ACCORD) trial was prematurely discontinued, following the observation of an increase in overall mortality, cardiovascular- related deaths, and severe hypoglycemic events.3 The action in diabetes and vascular disease; preterAx and diamicroN-MR controlled evaluation (ADVANCE) study also failed to show a statistically significant clinical benefit, while more adverse effects were seen among those who achieved a median HbA1c level of 6.4%.4 More intensive treatments with tight glycemic control targets are more costly and associated with increased patient burdens. Only Hollan et al8 reported a long-term benefit with intensive therapy in the United Kingdom prospective diabetes study (UKPDS) after 10 years of intervention.
Open Journal PUBLISHERS Editorial Population-Based Strategy for Preventing Diabetes and its Complications 1,2* Shaw Watanabe, MD, PhD1,2* 1Lifescience Promoting Association, Daikyo-cho 25-3-1004, Shinjuku-ku, Tokyo 160-0015, Japan 2Asia Pacific Clinical Nutrition Society (APCNS), Department of Food Science and Nutrition, Zhejiang University, 866 Yu-Hang-Tang Road, Hangzhou 310058, China * *Corresponding author Shaw Watanabe, MD, PhD Lifescience Promoting Association, Daikyo-cho 25-3-1004, Shinjuku-ku, Tokyo 160-0015, Japan; Fax: +81-3-5379-7786; E-mail: watashaw@lifescience.or.jp Article information th st st Received: March 19 , 2018; Accepted: March 21 , 2018; Published: March 21 , 2018 Cite this article Watanabe S. Population-based strategy for preventing diabetes and its complications. Diabetes Res Open J. 2018; 4(1): e1-e4. doi: 10.17140/DROJ-4-e011 “PROPER OR NOT” OF INTENSIVE THERAPY In the Steno-2 study; however, the number of subjects was small and the average HbA1c percentage also remained at a recent report from the American College of Physicians (ACP) considerably higher level than the target value in the intensified 10-12 should cause a paradigm change for the treatment of diabetic therapy group. Accordingly, the J-Doit-3 study was planned in A 1 patients. The main purpose of diabetes therapy is the prevention Japan, in which 2542 patients were randomly assigned either to or- of complications.2 The endpoint of many clinical trials is to lower dinary therapy or intensive therapy, and followed-up for a median 13,14 blood glucose levels, but intensive treatments aimed at lowering period of 8.5 years. The goals of the intensive therapy and ordi- the HbA1c to less than 6.5% are often accompanied by hypoglyce- nary therapy were set as follows: HbA1c (<6.2% vs. <6.9%), blood mia as a side effect. At the same time, intensive regimens have not pressure (<120/75 mmHg vs. <130/80 mmHg), LDL cholesterol shown a reduction of cardiovascular complications in the long- (<80 mg/dL vs. <120 mg/dL), HDL cholesterol (≥ 40 mg/dL vs. 3-7 term.3-7 For example, the action to control cardiovascular risk in ≥ 40 mg/dL), triacylglycerol (<120 mg/dL vs. <150 mg/dL), BMI diabetes (ACCORD) trial was prematurely discontinued, following (≤22 vs. ≤24), respectively. A primary outcome occurred in 109 the observation of an increase in overall mortality, cardiovascu- patients in the intensive therapy group and in 133 patients in the lar-related deaths, and severe hypoglycemic events.3 The action in conventional therapy group (hazard ratio [HR] 0.81, p=0.094). All- diabetes and vascular disease; preterAx and diamicroN-MR con- cause mortality (HR 1.01, p=0.95) and coronary events (myocar- trolled evaluation (ADVANCE) study also failed to show a statisti- dial infarction, coronary artery bypass surgery, and percutaneous cally significant clinical benefit, while more adverse effects were transluminal coronary angioplasty; HR 0.86, p=0.44) did not differ seen among those who achieved a median HbA1c level of 6.4%.4 between groups, but cerebrovascular events (stroke, carotid end- More intensive treatments with tight glycemic control targets are arterectomy, percutaneous transluminal cerebral angioplasty, and more costly and associated with increased patient burdens. Only carotid artery stenting) were significantly less frequent in the inten- Hollan et al8 reported a long-term benefit with intensive therapy in sive therapy group (HR 0.42, p=0.02). During a median follow-up the United Kingdom prospective diabetes study (UKPDS) after of 8.5 years, lowered risks of cerebral hemorrhage and nephropa- 10 years of intervention.
thy were observed, but hypoglycemia occurred in 41.1% patients in the intensive treatment vs. 22.3% in the control group. Multidrug intervention trials were also reviewed. The Ste- no-2 study planned to examine if multifactorial interventions (in- IDENTIFICATION OF HIGH-RISK DIABETIC PATIENTS FOR cluding behavior interventions) meant to decrease blood glucose, INTENSIVE THERAPY blood pressure and lipids in type-2 diabetes patients, could reduce the risks of microangiopathy, macroangiopathy, and premature The J-Doit-3 study suggested that multidrug therapy prevented re- deaths.9 After a median follow-up of 13.3 years, an overall 20% nal insufficiency. Thus, in a public seminar “Challenge to overcome absolute reduction in the risk of death (or decreased hazard ratio kidney disease”, the Japan Kidney Society and the Japan Diabetes of 0.54 for death) was observed in the intensive-therapy group, as Society jointly recommended that family doctors refer patients to a compared with the conventional-therapy group.
specialist when diabetic kidney disease is suspected.15 cc Copyright 2018 by Watanabe S. This is an open-access article distributed under Creative Commons Attribution 4.0 International License (CC BY 4.0), which allows to copy, redistribute, remix, transform, and reproduce in any medium or format, even commercially, provided the original work is properly cited. Every year in Japan, more than 10,000 patients progress elderly people, involving in particular cardiac, renal, and respiratory to renal failure and receive hemodialysis as complications of diabe- functions, and muscle strength. Decreasing insulin secretion being tes.16 The medical cost of treating a total of 300,000 patients with just one aspect of the problem, an integrated strategy is necessary dialysis is expected to exceed 1.5 trillion yen. Prevention of DKD to cover the full range of diabetes complications. Simple hypergly- is thus cost-saving public health priority.
cemia without hypertension and renal failure could easily be con- trolled by dietary and physical activity.25 Recently, Scandinavian researchers have categorized dia- betes mellitus into three severe and two mild forms.17 Data were Multiple chronic conditions are common in older popula- consolidated between five cohorts: Swedish All New Diabetics in tions. The frequency of polypharmacy and potential drug interac- Scania, Scania Diabetes Registry, All New Diabetics in Uppsala, tions make it difficult to balance the benefits and harms of therapy Diabetes Registry Vaasa, and Malmö Diet and Cancer Cardiovas- in older patients. For patients with multiple comorbid conditions, cular Arm. They used six variables for the cluster analysis of 8980 (e.g., renal failure, liver failure, end-stage disease, cognitive impair- patients, all of whom were newly diagnosed with diabetes between ment, advanced microvascular or macrovascular complications, or 2008 and 2016. Variables included: the presence of glutamic acid any other conditions that limit life expectancy), the harms of set- decarboxylase antibody (GADA); age at diagnosis; BMI; HbA1c; ting more stringent HbA1c targets outweigh their benefits. More homeostatic model assessment 2 (HOMA2) and insulin-resistance recent guidelines discuss the role of less intensive treatment for (HOMA2-IR), based on C-peptide concentrations.
older patients, to minimize symptoms rather than achieve a specific 26-28 HbA1c target.
The analysis revealed the presence of five clusters of dia- betes. Cluster 1: Severe autoimmune diabetes (SAID), Cluster 2: The ACP has proposed that the treatment of diabetes Severe insulin-deficient diabetes (SIDD), Cluster 3: Severe insulin- for the older person aged more than 80 years should primarily be resistant diabetes (SIRD), Cluster 4: Mild obesity-related diabetes adjusted to their quality of life (QOL).1 The American Diabetes (MOD) and Cluster 5: Mild age-related diabetes (MARD). Cluster Association (ADA) guidelines of 2017 raise psychosocial issues 2 patients had substantially higher HbA1c levels and diabetic reti- in a number of areas, including the self-management of diabetes nopathy was more common than in other clusters. Patients in clus- and the management of co-morbid conditions. Doctors should be- ter 3 had a substantially higher risk of end-stage renal disease. Such come familiar with existential therapy or holistic treatment, among a clinically useful stratification is an important step towards tailor- techniques that can achieve behavioral changes in patients. made precision medicine in diabetes. A low-protein diet is effective to reverse the progression to kidney failure, and low-protein rice is DIETARY INTERVENTION AS A POPULATION STRATEGY 18-20 easily available to decrease protein from diet.
The cross-sectional study on dietary habit and health (GENKI IMPORTANCE OF PRIMARY PREVENTION IN AGING SOCIETY study) clarified the characteristics of obese people and brown rice 29,30 eaters among 6000 participants. Obese people have lifestyle- In Japan, the number of diabetic patients has been steadily increas- related diseases, such as diabetes, hypertension, hyperlipidemia, ing, with 604 million (6.6%) in 1990,714 million (7.1%) in 2000, gout, bronchitis and gallstones, and they typically take medications 830 million (7.9%) in 2010, and it is estimated to rise to 971 mil- for these diseases with an increased odds ratio (OR) between 2 and lion (9.8%) in 2030.21 Worldwide, the number of diabetic patients 3. They felt unhealthy and lost vivid feeling in daily life. They spent is about 425 million, including 110 million in China, 73 million in a sedentary life, preferring fatty foods and meat, to vegetables, and India, and 30 million in United States.22 ate until full stomach.
Changes in lifestyle, such as sedentary life and western On the contrary, brown rice eaters consume significantly style high-calorie diet, and resulting obesity account for the in- more carrots, green yellow vegetables, radish, ginger, burdock, lo- crease seen in diabetic patients. Furthermore, in Japan the aging of tus root, sweet potatoes, yam, salty plum pickles (umeboshi), sesame, the population is an additional risk, reflecting stable changes in the peanut, chestnut, mushroom, dried mushroom (shiitake), dried rad- age adjustment. Japanese people tend to become diabetic even if ish, dried seaweed (nori), kelp (konbu), red bean (azuki), and soy they are mildly obese, compared with West Caucasians, i.e., 7-8% milk. They did not consume meat, but soy protein was substituted of Caucasians become diabetic at a BMI 30, while one fourth be- to meat and fish. They felt healthy and vivid, became better com- comes diabetic at the same BMI in Japan.23 pared to the previous year, and showed low OR for lifestyle-related diseases (OR=around 0.3).
Obese people are a pre-diabetic population, where a pop- ulation approach could be effective through the control of intake It has been clarified in recent studies, that brown rice energy sources and an increase in physical activity.24 However, this contains functional ingredients, such as dietary fibres, ferulic acids, is difficult to achieve in most patients unwilling to change their GABA, and antioxidants. They keep a good balance of the bacte- lifestyle.
rial flora and of the immune system. Considering that obesity is associated with various diseases, it is important to consider brown A physiological deterioration is commonly observed in rice among interventions to control obesity.31